SELF-IDENTIFICATION OF HANDICAP
(See Instructions and Privacy Act information on reverse)
Last Name, First Name, Middle Initial
Birth Date (Mo./Yr.)
Social Security Number
Enter Code Here _______
DEFINITION OF A HANDICAP:
A person is handicapped 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 handicaps that are to be reported are listed below (codes in bold numbers 13through 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 handicap status is essential for effective date 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 handicap status.  (Please read the employee note above and the reverse side of this form 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 handicap.
06- I have a handicap, 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); laryngectomy (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 or 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
45- One or both feet
46- One or both arms
47- One or both legs
48- Hip or pelvis
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
76- Lower half of body, including legs
77- One side of body, including one arm and one leg
78- three or more major parts of the body (arms and legs)
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 disfunctioning (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)
256-104
7540-026-2848
Previous edition unusable
Standard Form 256 (Rev. 8/87)
U.S. Office of Personnel Management
FPM Supplement 296-1
The Rehabilitation Act of 1973 (P.L. 93-112) requires each agency in the Executive branch of the Federal government to establish definite programs that will facilitate the hiring, placement, and advancement of handicapped individuals.  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 handicapped employees hired, promoted, trained, or reassigned over a given time period; the percentage of handicapped employees in the work force and in various grades and occupations; etc.  Such reports bring to the attention of agency top management, the 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 handicapped individuals and, therefore, are the essential first step in improving these conditions and consequently meeting the requirements of the Rehabilitation Act.
The handicap 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 in the strictest confidence and is known only to the one or two 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 handicap reporting system is entirely voluntary, with the exception of employees appointed under Schedule A, section 213.3102(u) (Severely Physically Handicapped); and Schedule B, section 213.3202(k) (Mentally Restored).  These employees will be requested to identify their handicap status and if they decline to do so, their correct handicap code will be obtained from medical documentation used to support their appointment.   No other employees will be required to identify their handicap status if they feel for any reason it is not in their best interests to have this information officially recorded outside of medical records.  We request only that anyone not wishing to have this information entered in the agency's and OPM's personnel systems indicate this to their Personnel Office, rather than intentionally miscoding themselves, since false responses will seriously damage the statistical value of the reporting system.
(In those instances where the employee is or was hired under Schedule A, section 213.3102(t) (Mental Retardation), the Personnel Director or his/her designee (a Vocational Rehabilitation Counselor may also be helpful) will assist the individual in completing this form and ensure that the employee fully understands the meaning of the form and the options available to him/her, as noted above.)
Employees will be given every opportunity to ensure that the handicap 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 record, by notifying Personnel any time their handicap status changes, and by initialing action in either of these cases to have the necessary changes made to their records.  The code carried on employees in their agency's system will be identical to that carried in OPM's system, and any change to the agency records will result in the same change being made to OPM's records.
Your cooperation and assistance in establishing and maintaining an accurate and up-to-date handicap report system is sincerely appreciated.
PRIVACY ACT STATEMENT
Collection of the requested information is authorized by the Rehabilitation Act of 1973 (P.L. 93-112).  The information you furnish will be used for the purpose of producing statistical reports to show agency progress in hiring, placement, and advancement of handicapped individuals and to locate individuals for voluntary participation in surveys.  The reports will be used to inform agency top management, the Office of Personnel Management (OPM), the Congress, and the public of the status of programs for employment of the handicapped.  All such reports will be in the form of aggregate totals and will not identify you in any way as an individual.
Solicitation of your Social Security Number (SSN) is authorized by Executive Order 9397, which requires agencies to use the SSN as the means for identifying individuals in personnel information systems.  Your SSN will only be used to ensure that your correct handicap code is recorded along with the other employee information that your agency and OPM maintain on you.  Furnishing your SSN or any other of the requested data 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 will be obtained from other records in order to ensure accurate and complete data.
Employees appointed under Schedule A, section 213.3102(t) (Mental Retardation), Schedule A, section 213.3102(u) (Severely Physically Handicapped), or Schedule B, section 213.3202(k) (Mentally Restored) are requested to furnish an accurate handicap code, but failure to do so will have no effect on them.  Where employees hired under one of these appointments fail to disclose their handicap, however, the appropriate code will be determined from the employee's existing records or medical documentation submitted to justify the appointment.
Standard Form 256 BACK
*U.S. GPO: 1991-0-290-490/20214