Identification of Handicapped, Disabled Veterans and Vietnam Era Veterans


The University of Akron is a government contractor subject to Section 503 and 504 of the Rehabilitation Act of 1973 and Section 402 of the Vietnam Era Readjustment Assistance Act of 1974 requiring the University to maintain a list of handicapped individuals, disabled veterans and veterans of the Vietnam Era.

If you are handicapped, a disabled veteran or a veteran of the Vietnam Era, the EEO/AA Office would like to be informed. This can be accomplished by completing the form below. Submission of this information is completely voluntary and will be kept confidential, except that:

Supervisors may be informed if the restriction(s) of the handicapped individual requires reasonable accommodation in order that he/she may perform his/her duties.

Safety personnel may be informed when and to what extent the condition might require emergency treatment.

Government officials may be informed during the course of investigating compliance with the above mentioned acts.

The information you requested regarding my status as handicapped, disabled veteran
or veteran Era veteran is detailed below. I understand that it will be kept confidential with
the exceptions noted under "Identification of handicapped, Disabled veterans and vietnam
era Veterans." I have checked those areas that apply to me.

 

Permanent Handicap Information

1. Impairment to locomotion requiring a wheelchair or other wheeled convinience
2. Impairment to locomotion requiring canes, or braces to walk, or else slowness of gait
3. Impairment to upper limbs or hands, including problems of manipulation, hand dexterity, reaching, pushing, or pulling
4. Impairment to sight with little or no functional vision.
5. Impairment of hearing not correctible with hearing aids.
6. Impairment of speech, perception or reading.
7. Chronic health problems(e.g., dialysis, respiratory, cardiac and other conditions requiring frequent medical attention that may impair daily functioning).

8. Other
Handicapped
Disabled veteran
Vietnam Era vet

 
Please Print the following Information:

Name


Department


Extension 


ZIP


Date


If you have any questions regarding this form, please call the 
Equal Employment Oppurtunity Office at ext.7300