GENDER, ETHNICITY, RACE, AND DISABILITY SELF-IDENTIFICATION

(Please read the instructions and Privacy Act Information)

Privacy Act Statement

You are requested to furnish this information under the authority of 42 U.S.C. 2000e-16, which requires that Federal employment practices be

free from discrimination and provide equal employment opportunities for all. Solicitation of this information is in accordance with the Office of

Management and Budget’s Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity, 66 FR 3829 (2001) and

authorized by the Rehabilitation Act of 1973 (P.L. 93-112).

This information will be used in planning and monitoring equal employment opportunity programs and to identify employees for inclusion in skill

banks and referral pools. Your furnishing this information is voluntary. Your failure to do so will have no effect on you or on your Federal

employment. If you fail to provide the information, however, then the employing Agency will attempt to identify your race and national origin

independently, and inform you (the employee) of the data the employing agency will be reporting (in accordance with 29 C.F.R. sec. 1614.601).

You are requested to furnish your Social Security number (SSN) under the authority of Executive Order 9397 (November 22, 1943). That Order

requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of personnel records. Because your

personnel records are identified by your SSN, your SSN is being requested on this form so that the other information you furnish on this form can

be accurately included with your records.

***PLEASE READ AND COMPLETE SECTIONS 1, 2, 3, and 4***

SECTION 1: Specific Instructions: Please review the categories below and check the box corresponding to the category

that identifies your gender. Note: Check only ONE box.

Male

SECTION 2: Specific Instructions: Please review the categories below and check the box corresponding to the category

that identifies your ethnicity. Note: Check only ONE box.

Name (Last, First, Middle Initial) Birth Date (MM/DD/YY) Social Security Number Agency Use Only

Female

SECTION 3: Specific Instructions: Please review each category below and check the box corresponding to the category

that identifies your race/national origin. Note: You may check more than one box, as appropriate.

NAME OF CATEGORY

Hispanic or Latino A person of Mexican, Puerto Rican, Cuban, Central or South American, or other

Spanish culture or origins, regardless of race.

Not Hispanic or Latino A person not of Mexican, Puerto Rican, Cuban, Central or South American or

Spanish cultures.

DEFINITION OF CATEGORY

NAME OF CATEGORY

American Indian or

Alaska Native

A person having origins in any of the original peoples of North America, or

Central and South America.

DEFINITION OF CATEGORY

Asian A person having origins in any of the original peoples of the Far East,

Southeast Asia, or the Indian sub-continent including, for example, Cambodia,

China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands,

Thailand, and Vietnam.

Black or African

American

A person having origins in any of the black racial groups of Africa.

Native Hawaiian or

other Pacific Islander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa,

or other Pacific Islands.

White A person having origins in any of the original peoples of Europe, North Africa,

or the Middle East.

DIA FORM 418
SECTION 4: Specific Instructions: Please review the categories below and enter your primary disability code in the first box on the

right and your secondary disability code in the second box.

DEFINITION OF A DISABILITY: A person has a disability if he or

she has a physical or mental impairment which substantially limits

one or more major life activities; has a record of such impairment;

or is regarded as having such impairment. Those disabilities that

are to be reported are listed below (codes in bold numbers 13

through 94). In the case of multiple impairments, choose the code

which describes the impairment that would result in the most substantial limitation.

TO THE EMPLOYEE: 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.

01 I do not wish to identify my disability status. (Please read the employee

note above before using this code.) (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 below.

SPEECH IMPAIRMENTS

13 Severe speech malfunction or inability to speak; hearing is normal

(Examples: defects of articulation [unclear language sounds];

stuttering; aphasia [impaired language function]; removal of the “voice

box”)

HEARING IMPAIRMENTS

15 Hard of hearing (Total deafness in one ear or inability to hear ordinary

conversation, correctable with a hearing aid)

16 Total deafness in both ears, with understandable speech

17 Total deafness in both ears, and unable to speak clearly

VISION IMPAIRMENTS

22 Ability to read ordinary size print with glasses, but with loss of peripheral

(side) vision (Restriction of the visual field to the extent that mobility is

affected—“Tunnel Vision”)

23 Inability to read ordinary size print, not correctable by glasses (Can read

oversized print or use assisting devices such as glass or projector modifier)

24 Blind in one eye

25 Blind in both eyes (No usable vision, but may have some light perception)

MISSING EXTREMITIES

27 One hand

28 One arm

29 One foot

32 One leg

33 Both hands and arms

34 Both feet or legs

35 One hand or arm and one foot or leg

36 One hand or arm and both feet or legs

37 Both hands or arms and one foot or leg

38 Both hands or arms and both feet or legs

NONPARALYTIC ORTHOPEDIC IMPAIRMENTS

(Because of chronic pain, stiffness, or weakness in bones or joints, there is

some loss of ability to move or use a part or parts of the body.)

44 One or both hands 47 One or both legs

45 One or both feet 48 Hip or pelvis

46 One or both arms 49 Back

57 Any combination of two or more parts of the body

PARTIAL PARALYSIS

(Because of a brain, nerve, or muscle problem, including palsy and cerebral

palsy, there is some loss of ability to move or use a part of the body, including

legs, arms, and/or trunk.)

61 One hand

62 One arm, any part

63 One leg, any part

64 Both hands

65 Both legs, any part

66 Both arms, any part

67 One side of body, including one arm

and one leg

68 Three or more major parts of the

body (arms and legs)

COMPLETE PARALYSIS

(Because of a brain, nerve, or muscle problem, including palsy and cerebral

palsy, there is a complete loss of ability to move or use a part of the body,

including legs, arms, and/or trunk.)

70 One hand

71 Both hands

72 One arm

73 Both arms

74 One leg

75 Both legs

78 Three or more major parts of the

body (arms and legs)

76 Lower half of body, including legs

77 One side of body, including one arm

and one leg

OTHER IMPAIRMENTS

80 Heart disease with no restriction or limitation of activity (History of heart

problems with complete recovery)

81 Heart disease with restriction or limitation of activity

82 Convulsive disorder (e.g., epilepsy)

83 Blood diseases (e.g., sickle cell anemia, leukemia, hemophilia)

84 Diabetes

86 Pulmonary or respiratory disorders (e.g., tuberculosis, emphysema,

asthma)

87 Kidney dysfunctioning (e.g., if dialysis [Use of an artificial kidney machine]

is required)

88 Cancer—a history of cancer with complete recovery

89 Cancer—undergoing surgical and/or medical treatment

90 Mental retardation (A chronic and lifelong condition involving a limited ability

to learn, to be educated, and to be trained for useful productive employment as certified by a State Vocational Rehabilitation agency under section

213.3102(t) of Schedule A)

91 Mental or emotional illness (A history of treatment for mental or emotional

problems)

92 Severe distortion of limbs and/or spine (e.g., dwarfism, kyphosis [severe

distortion of back])

93 Disfigurement of face, hands, or feet (e.g., distortion of features on skin,

such as those caused by burns, gunshot injuries, and birth defects [gross

facial birthmarks, club feet, etc.])

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)

DIA FORM 418

Name (Last, First, Middle Initial) Social Security Number Birth Date (MM/DD/YY) Enter Primary Code Here

Enter Secondary Code Here