ETA Form 671, Part Voluntary Disability Disclosure

ETA Form 671, Part IIA for Apprenticeship Agreement and Apprentice Registration

Voluntary Disability Disclosure OMB No. 1205-0NEW | Expires: xx/xx/xxxx

Why am I being asked to complete this form?

Because we are a sponsor of a registered apprenticeship program and participate in the National Registered Apprenticeship System that is regulated by the U.S. Department of Labor, we must reach out to, enroll, and provide equal opportunity in apprenticeship to qualified people with disabilities.^[1] To help us learn how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for apprenticeship, any answer you give will be kept private and will not be used against you in any way.

If you already are an apprentice within our registered apprenticeship program, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our apprentices at the time of enrollment, and then remind them yearly, that they may update their information. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

• Alcohol or other substance use disorder (not currently using drugs illegally)

• Autoimmune condition, for example lupus, HIV/AIDS, rheumatoid arthritis, etc.

• Blind or low vision

• Brain or spinal cord injury

• Cancer

• Celiac disease

• Cerebral palsy

• Deaf or hard of hearing

• Depression or anxiety

• Diabetes

• Disfigurement, for example, disfigurement caused by burns, wounds, accidents, missing limbs, or congenital disorders

• Epilepsy or other seizure disorder

• Gastrointestinal condition, for example, Chron’s disease, ulcerative colitis, etc.

• Heart/respiratory condition

• Intellectual disability

• Mental health condition, for example, depression, PTSD, schizophrenia, bipolar disorder, OCD, etc.

• Nervous system condition, for example, migraine headaches, multiple sclerosis (MS), Parkinson’s disease, etc.

• Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities

• Partial or complete paralysis (any cause)

• Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema

• Short stature (dwarfism)

• Traumatic brain injury

Name: ______________________________ Date: ___________________________________

☐	Yes, I have a disability (or previously had a disability)
☐	No, I don’t have a disability
☐	I don’t wish to answer

Please check one of the boxes below.

[1] Part 30 – Equal Employment Opportunity in Apprenticeship. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Apprenticeship website at https://www.apprenticeship.gov/eeo.

ETA 671, Part IIA