The University of Oregon is a federal contractor subject to Section 503 of the Rehabilitation Act of 1973, as amended, which requires federal contractors to take affirmative action to employ and advance in employment qualified individuals with disabilities. The University of Oregon also is subject to the Americans with Disabilities Act (ADA). Under both the Rehabilitation Act and the ADA, a qualified individual with a disability may be entitled to reasonable accommodation where that would enable that individual to perform the essential duties of his or her position properly and safely. If you are an individual with a disability and 1) would like to be considered under the affirmative action program, and/or 2) would like to be contacted confidentially regarding your disability and possible need for accommodation, please complete and return this form as instructed below. Please note that submission of this information is voluntary and a decision not to provide it will not subject you to any adverse treatment. You may inform the university of your desire to benefit under the program and/or request reasonable accommodation at this time or at any time in the future. The information you provide in this self-identification form regarding your disability will be kept confidential except as expressly allowed under the Rehabilitation Act and the ADA.
NAME: ________________________________________________________
DEPARTMENT: _________________________________________________
UNCLASSIFIED
CLASSIFIED STAFF
Check if applicable: ___ Individual with Disability*
*Under the Rehabilitation Act of 1973 and the Americans with Disabilities Act, "Individual with a Disability" means any person who: i. Has a physical or mental impairment which substantially limits one or more of that person's major life activities; ii. Has a record of such an impairment; or iii. Is regarded as having such an impairment.
Would you like to be contacted confidentially regarding your disability?
YES NO
CAMPUS PHONE: _______________
If at any time in the future you wish to self-identify, please contact the Office of Affirmative Action and Equal Opportunity. Tel: (541) 346-3123; Fax: (541) 346-4168; TTY (541) 346-6203.
This form is available in alternative formats by contacting the Office of Affirmative Action and Equal Opportunity as noted above.
Please return in a sealed envelope marked "Confidential" to: Director, Office of Affirmative Action & Equal Opportunity 474 Oregon Hall, 5221 University of Oregon, Eugene, OR 97403-5221.
