SECTION 1 – Survey Information and Confidentiality
The completion of this form is voluntary. The information is used only to provide a better idea of how well the State of Virginia is doing in terms of recruiting and employing available disabled people. Your assistance would be appreciated. Assurance of Confidentiality – The voluntary information requested for this survey shall be confidential. Definition of Disabled Individual – For the purpose of this form, the term Disabled Individual shall mean: An individual who: 1) has a physical or mental impairment which substantially limits one or more of such individual’s major life activities; or 2) has a record of such impairment; or 3) is regarded as having such an impairment. A disabled individual is considered “substantially limited” if he or she is likely to experience difficulty in securing, retaining or advancing in employment or education because of a disability.
SECTION 2 – Certification of Disability
I am a “disabled individual” as defined above.
My disability(ies) is/are:
According to the Personnel Management Information System Disability Codes listed below, the appropriate code for my disability(ies) is/are: (check all that apply)
100	Blindness, both eyes	500	Other mental, psychoneurotic and personality disorders
101	Blindness, both eyes (some correction)
102	Blindness, one eye	501	Alcoholism
103	Other visual impairment	502	Drug Addiction
503	Mental Retardation, mild
200	Deafness, unable to talk	504	Mental Retardation, moderate
201	Deafness, able to talk	505	Mental Retardation, severe
202	Other hearing impairment
600	Malignancies
300	Impairment involving three or more (major) limbs	601	Allergies
301	Impairment involving one upper, one lower limb	602	Diseases of the blood
302	Impairment involving one or two upper limbs	603	Epilepsy
303	Impairment involving one or two lower limbs	604	Cardiac, Circulatory and Respiratory
304	Other and ill-defined impairments	605	Digestive and Uro-genital
606	Speech Impairment
400	Amputation of at least one upper and one lower limb	607	Other
401	Amputation of one or two upper limbs
402	Amputation of one or two lower limbs	700	Multiple disabilities
403	Amputation of other and unspecified parts
The limitations or restrictions caused by my disability(ies) is/are: (briefly describe)
The following information is required for entering the above information into the Personnel Management Information System and shall be confidential.
Name:
Social Security Number:
Position Number:	Agency Number:	411 Department of Forestry