SF256.pdf

Page 1 of 2U.S. Office of Personnel Management

SF 256

Revised July 2010 Previous editions not usable

SELF-IDENTIFICATION OF DISABILITY

(see instructions and Privacy Act information on reverse)

Last Name, First Name, and MI Date of Birth (mm/yy) Social Security Number

ENTER CODE HERE――――― >

Definition:

An Individual with a disability: A person who (1) has a physical impairment or mental impairment (psychiatric disability) that substantially limits one or more of such person's major life activities; (2) has a record of such impairment; or (3) is regarded as having such an impairment. This definition is provided by the Rehabilitation Act of 1973, as amended (29 U.S.C. 701 et.

seq.).

Purpose:

Self-identification of disability status is essential for effective data collection and analysis. The information you provide will be used for statistical purposes only and will not in any way affect you individually. While self-identification is voluntary, your cooperation in providing accurate information is critical.

Part I. Targeted/Severe Disabilities

Hearing 18 - Total deafness in both ears (with or without understandable speech)

Vision 21 - Blind (inability to read ordinary size print, not correctable by glasses, or no usable vision, beyond light perception)

Missing Extremities 30 - Missing extremities (missing one arm or leg, both hands or arms, both feet or legs, one hand or arm and one foot or leg, one hand or arm and both feet or legs, both hands or arms and one foot or leg, or both hands or arms and both feet or legs)

Partial Paralysis 69 - Partial paralysis (because of a brain, nerve or muscle impairment, including palsy and cerebral palsy, there is some loss of ability to move or use a part of the body, including both hands; any part of both arms or legs; one side of the body, including one arm and one leg; and/or three or more major body parts)

Complete Paralysis 79 - Because of a brain, nerve or muscle impairment, including palsy and cerebral palsy, there is a complete loss of ability to move or use a part of the body, including both hands; one or both arms or legs; the lower half of the body; one side of the body, including one arm and one leg;

and/or three or more major body parts

Other Impairments 82 - Epilepsy 90 - Severe intellectual disability 91 - Psychiatric disability 92 - Dwarfism

Part II. Other Disabilities

Hearing Conditions 15 - Hearing impairment/hard of hearing

Vision Conditions 22 - Visual impairments (e.g., tunnel or monocular vision or blind in one eye)

Physical Conditions 26 - Missing extremities (one hand or one foot) 40 - Mobility impairment (e.g., cerebral palsy, multiple sclerosis, muscular dystrophy, congenital hip defects, etc.)

41 - Spinal abnormalities (e.g., spina bifida, scoliosis) 44 - Non-paralytic orthopedic impairments: chronic pain, stiffness, weakness in bones or joints, some loss of ability to use part or parts of the body

51 - HIV Positive/AIDS 52 - Morbid obesity 61 - Partial paralysis of one hand, arm, foot, leg, or any part thereof 70 - Complete paralysis of one hand 80 - Cardiovascular/heart disease with or without restriction or limitation on activity; a history of heart problems w/complete recovery 83 - Blood diseases (e.g., sickle cell anemia, hemophilia) 84 - Diabetes 86 - Pulmonary or respiratory conditions (e.g., tuberculosis, asthma, emphysema, etc.)

87 - Kidney dysfunction (e.g., required dialysis) 88 - Cancer (present or past history) 93 - Disfigurement of face, hands, or feet (such as those caused by burns or gunshot wounds) and noticeable gross facial birthmarks 95 - Gastrointestinal disorders (e.g., Crohn's Disease, irritable bowel syndrome, colitis, celiac disease, dysphexia, etc.)

98 - History of alcoholism

Speech/Language/Learning Conditions 13 - Speech impairment - includes impairments of articulation (unclear language sounds), fluency (stuttering), voice (with normal hearing), dysphasia, or history of laryngectomy

94 - Learning disability - a disorder in one or more of the processes involved in understanding, perceiving, or using language or concepts (spoken or written) (e.g., dyslexia, ADD/ADHD)

Other Options 01 - I do not wish to identify my disability status. (Please read the notes on the next page.) (Note: Your personnel officer may use this code if, in his or her judgment, you used an incorrect code.)

05 - I do not have a disability.

06 - I have a disability, but it is not listed on this form.

The Rehabilitation Act of 1973 The Rehabilitation Act, as amended (29 U.S.C. 701, et seq.), requires each agency in the executive branch of the Federal Government to establish programs that will facilitate the hiring, placement, and advancement of individuals with disabilities. The best means of determining agency progress in this respect is through the production of reports at certain intervals showing such things as the number of employees with disabilities who are hired, promoted, trained, or reassigned over a given time period; the percentage of employees with disabilities in the workforce and in various grades and occupations; etc. Such reports bring to the attention of agency top management, the U.S. Office of Personnel Management (OPM), and the Congress deficiencies within specific agencies or the Federal Government as a whole in the hiring, placement, and advancement of individuals with disabilities and, therefore, are the essential first step in improving these conditions and consequently meeting the requirements of the Rehabilitation Act.

The disability data collected on employees will be used only in the production of reports such as those previously mentioned and not for any purpose that will affect them individually. The only exception to this rule is that the records may be used for selective placement purposes and selecting special populations for mailing of voluntary personnel research surveys. In addition, every precaution will be taken to ensure that the information provided by each employee is kept to the strictest confidence and is known only to those individuals in the agency Personnel Office who obtain and record the information for entry into the agency's and OPM's personnel systems. You should also be aware that participation in the disability reporting system is entirely voluntary, with the exception of employees appointed under Schedule A, SECTION 213.3102(u) (Severe physical or mental disabilities). These employees will be requested to identify their disability status and if they decline to do so, their correct disability code will be obtained from medical documentation used to support their appointment.

Employees will be given every opportunity to ensure that the disability code carried in their agency's and OPM's personnel systems is accurate and is kept current. They may exercise this opportunity by asking their Personnel Officer to see a printout of the code and definition from their records . The code carried on employees in the agency's system will be identical to that carried in OPM's system.

Your cooperation and assistance in establishing and maintaining an accurate and up-to-date disability report system is sincerely appreciated.

Privacy Act Statement Collection of the requested information is authorized by the Rehabilitation Act, as amended (29 U.S.C. 701, et seq.). Solicitation of your Social Security Number (SSN) is authorized by Executive Order 9397, which permits agencies to use the SSN as the means for identifying persons with disabilities in personnel information systems. Your SSN will only be used to ensure that your correct disability code is recorded along with other employee information that your agency and OPM maintain on you. Furnishing your SSN or any other data requested for this collection effort is voluntary and failure to do so will have no effect on you. It should be noted, however, that where individuals decline to furnish their SSN, the SSN will be obtained from other records in order to ensure accurate and complete data. Employees appointed under Schedule A, Section 213.3102 (u) (Severe physical or mental disabilities) are requested to furnish an accurate disability code, but failure to do so will not affect them. Where employees hired under one of these appointing authorities fail to disclose their disability(ies), however, the appropriate code will be determined from the employee's existing records or medical documentation physically submitted upon appointment.

SF 256

Revised July 2010 Previous editions not usableU.S. Office of Personnel Management

Page of U.S. Office of Personnel Management

SF 256 Revised July 2010 Previous editions not usable

SELF-IDENTIFICATION OF DISABILITY

(see instructions and Privacy Act information on reverse) Last Name, First Name, and MI Date of Birth (mm/yy) Social Security Number

ENTER CODE HERE――――― >

Definition:

An Individual with a disability: A person who (1) has a physical impairment or mental impairment (psychiatric disability) that substantially limits one or more of such person's major life activities; (2) has a record of such impairment; or (3) is regarded as having such an impairment. This definition is provided by the Rehabilitation Act of 1973, as amended (29 U.S.C. 701 et. seq.).

Purpose:

Self-identification of disability status is essential for effective data collection and analysis. The information you provide will be used for statistical purposes only and will not in any way affect you individually. While self-identification is voluntary, your cooperation in providing accurate information is critical.

Part I. Targeted/Severe Disabilities Hearing 18 - Total deafness in both ears (with or without understandable speech)

Vision 21 - Blind (inability to read ordinary size print, not correctable by glasses,or no usable vision, beyond light perception)

Missing Extremities 30 - Missing extremities (missing one arm or leg, both hands or arms, both feet or legs, one hand or arm and one foot or leg, one hand or arm and both feet or legs, both hands or arms and one foot or leg, or both hands or arms and both feet or legs)

Partial Paralysis 69 - Partial paralysis (because of a brain, nerve or muscle impairment, including palsy and cerebral palsy, there is some loss of ability to move or use a part of the body, including both hands; any part of both arms or legs; one side of the body, including one arm and one leg; and/or three or more major body parts)

Complete Paralysis 79 - Because of a brain, nerve or muscle impairment, including palsy and cerebral palsy, there is a complete loss of ability to move or use a part of the body, including both hands; one or both arms or legs; the lower half of the body; one side of the body, including one arm and one leg; and/or three or more major body parts

Other Impairments 82 - Epilepsy 90 - Severe intellectual disability 91 - Psychiatric disability 92 - Dwarfism Part II. Other Disabilities Hearing Conditions 15 - Hearing impairment/hard of hearing

Vision Conditions 22 - Visual impairments (e.g., tunnel or monocular vision or blind in one eye)

Physical Conditions 26 - Missing extremities (one hand or one foot) 40 - Mobility impairment (e.g., cerebral palsy, multiple sclerosis, muscular dystrophy, congenital hip defects, etc.)

41 - Spinal abnormalities (e.g., spina bifida, scoliosis) 44 - Non-paralytic orthopedic impairments: chronic pain, stiffness, weakness in bones or joints, some loss of ability to use part or parts of the body 51 - HIV Positive/AIDS 52 - Morbid obesity 61 - Partial paralysis of one hand, arm, foot, leg, or any part thereof 70 - Complete paralysis of one hand 80 - Cardiovascular/heart disease with or without restriction or limitation on activity; a history of heart problems w/complete recovery 83 - Blood diseases (e.g., sickle cell anemia, hemophilia) 84 - Diabetes 86 - Pulmonary or respiratory conditions (e.g., tuberculosis, asthma, emphysema, etc.)

87 - Kidney dysfunction (e.g., required dialysis) 88 - Cancer (present or past history) 93 - Disfigurement of face, hands, or feet (such as those caused by burns or gunshot wounds) and noticeable gross facial birthmarks 95 - Gastrointestinal disorders (e.g., Crohn's Disease, irritable bowel syndrome, colitis, celiac disease, dysphexia, etc.)

98 - History of alcoholism

Speech/Language/Learning Conditions 13 - Speech impairment - includes impairments of articulation (unclear language sounds), fluency (stuttering), voice (with normal hearing), dysphasia, or history of laryngectomy 94 - Learning disability - a disorder in one or more of the processes involved in understanding, perceiving, or using language or concepts (spoken or written) (e.g., dyslexia, ADD/ADHD)

Other Options 01 - I do not wish to identify my disability status. (Please read the notes on the next page.) (Note: Your personnel officer may use this code if, in his or her judgment, you used an incorrect code.)

05 - I do not have a disability.

06 - I have a disability, but it is not listed on this form.

The Rehabilitation Act of 1973 The Rehabilitation Act, as amended (29 U.S.C. 701, et seq.), requires each agency in the executive branch of the Federal Government to establish programs that will facilitate the hiring, placement, and advancement of individuals with disabilities. The best means of determining agency progress in this respect is through the production of reports at certain intervals showing such things as the number of employees with disabilities who are hired, promoted, trained, or reassigned over a given time period; the percentage of employees with disabilities in the workforce and in various grades and occupations; etc. Such reports bring to the attention of agency top management, the U.S. Office of Personnel Management (OPM), and the Congress deficiencies within specific agencies or the Federal Government as a whole in the hiring, placement, and advancement of individuals with disabilities and, therefore, are the essential first step in improving these conditions and consequently meeting the requirements of the Rehabilitation Act.

The disability data collected on employees will be used only in the production of reports such as those previously mentioned and not for any purpose that will affect them individually. The only exception to this rule is that the records may be used for selective placement purposes and selecting special populations for mailing of voluntary personnel research surveys. In addition, every precaution will be taken to ensure that the information provided by each employee is kept to the strictest confidence and is known only to those individuals in the agency Personnel Office who obtain and record the information for entry into the agency's and OPM's personnel systems. You should also be aware that participation in the disability reporting system is entirely voluntary, with the exception of employees appointed under Schedule A, SECTION 213.3102(u) (Severe physical or mental disabilities). These employees will be requested to identify their disability status and if they decline to do so, their correct disability code will be obtained from medical documentation used to support their appointment.

Employees will be given every opportunity to ensure that the disability code carried in their agency's and OPM's personnel systems is accurate and is kept current. They may exercise this opportunity by asking their Personnel Officer to see a printout of the code and definition from their records . The code carried on employees in the agency's system will be identical to that carried in OPM's system.

Your cooperation and assistance in establishing and maintaining an accurate and up-to-date disability report system is sincerely appreciated.

Privacy Act Statement Collection of the requested information is authorized by the Rehabilitation Act, as amended (29 U.S.C. 701, et seq.). Solicitation of your Social Security Number (SSN) is authorized by Executive Order 9397, which permits agencies to use the SSN as the means for identifying persons with disabilities in personnel information systems. Your SSN will only be used to ensure that your correct disability code is recorded along with other employee information that your agency and OPM maintain on you. Furnishing your SSN or any other data requested for this collection effort is voluntary and failure to do so will have no effect on you. It should be noted, however, that where individuals decline to furnish their SSN, the SSN will be obtained from other records in order to ensure accurate and complete data. Employees appointed under Schedule A, Section 213.3102 (u) (Severe physical or mental disabilities) are requested to furnish an accurate disability code, but failure to do so will not affect them. Where employees hired under one of these appointing authorities fail to disclose their disability(ies), however, the appropriate code will be determined from the employee's existing records or medical documentation physically submitted upon appointment.

SF 256 Revised July 2010 Previous editions not usable U.S. Office of Personnel Management Willie Powers Gina Moriarty

SF256

October 23,2008 October 23,2008