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Disability Self Identification Form
Fill in the required fields below
	* First Name:		First name is required
	* Last Name:		Last name is required
	Department/Office:
	* Building:		Building is required
	* Room #:		Room is required
	* Work Phone #:		Work phone is required
	E-mail Address:		Email format is incorrect
	Personal Address:
	* Preferred Phone:		Preferred phone is required
	Please check the category (ies) that applies:
		Newly Separated Veterans
		Defined as any veteran who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veteran's discharge or release from active duty.
		Veteran of the Vietnam-era
		Means a person who: (1) Served in the military, ground, naval or air service of the United States on active duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any part of such active duty occurred: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (II) between August 5, 1964 and May 7, 1975 in all other cases; or (2) Was discharged or released from active duty for a service connected disability if any part of such active duty was performed: (I) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (II) between August 5, 1964, and May 7, 1975, in all other cases.
		Special disabled veteran
		means: (1) A veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability (i) rated at 30 percent of more, or (ii) rated at 10 or 20 percent if it has been determined that the individual has a serious employment disability; or (2) A veteran who was discharged or released from active duty because of a service-connected disability.
		Other protected veteran
		Is defined as a veteran who served in the military, ground, naval or air service of the United States on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized. A complete list of campaigns can be viewed at: http://www.fedshirevets.gov/hire/hrp/vetguide/index.aspx


	Describe any accomodation(s), if needed, to perform the job:


	Alternatively return completed forms to:
	By mail:		You can fill out the form and then Print it instead of clicking submit. Mail it to: Director, Office of Personnel Queensborough Community College 222-05 56th Ave. Room: 412 Admin. Bldg. Bayside, NY 11364