01 |
I do not wish to identify my disability or serious health condition. |
10/01/2016
|
Present
|
02 |
Developmental Disability, for example, autism spectrum disorder |
10/01/2016
|
Present
|
03 |
Traumatic Brain Injury |
10/01/2016
|
Present
|
05 |
I do not have a disability or serious health condition. |
10/01/2016
|
Present
|
06 |
I have a disability or serious health condition, but it is not listed on this form. |
10/01/2016
|
Present
|
13 |
Speech impairment |
10/01/2016
|
Present
|
19 |
Deaf or serious difficulty hearing, benefiting from, for example, American Sign Language, CART, hearing aids, a cochlear implant and/or other supports |
10/01/2016
|
Present
|
20 |
Blind or serious difficulty seeing even when wearing glasses |
10/01/2016
|
Present
|
31 |
Missing extremities (arm, leg, hand and/or foot) |
10/01/2016
|
Present
|
40 |
Significant mobility impairment, benefiting from the utilization of a wheelchair, scooter, walker, leg brace(s) and/or other supports. |
10/01/2016
|
Present
|
41 |
Spinal abnormalities, for example, spina bifida or scoliosis |
10/01/2016
|
Present
|
44 |
Non-paralytic orthopedic impairments, for example, chronic pain, stiffness, weakness in bones or joints, some loss of ability to use part or parts of the body. |
10/01/2016
|
Present
|
51 |
HIV Positive/AIDS |
10/01/2016
|
Present
|
52 |
Morbid obesity |
10/01/2016
|
Present
|
59 |
Nervous system disorder for example, migraine headaches, Parkinson’s disease, or multiple sclerosis |
10/01/2016
|
Present
|
60 |
Partial or complete paralysis (any cause) |
10/01/2016
|
Present
|
80 |
Cardiovascular or heart disease. |
10/01/2016
|
Present
|
81 |
Depression, anxiety disorder, or other psychiatric disorder |
10/01/2016
|
Present
|
82 |
Epilepsy or other seizure disorders |
10/01/2016
|
Present
|
83 |
Blood diseases, for example, sickle cell anemia, hemophilia. |
10/01/2016
|
Present
|
84 |
Diabetes |
10/01/2016
|
Present
|
85 |
Orthopedic impairments or osteo-arthritis |
10/01/2016
|
Present
|
86 |
Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema |
10/01/2016
|
Present
|
87 |
Kidney Dysfunction. |
10/01/2016
|
Present
|
88 |
Cancer (Present or past history). |
10/01/2016
|
Present
|
90 |
Intellectual Disability. |
10/01/2016
|
Present
|
91 |
Significant Psychiatric Disorder, for example, bipolar disorder, schizophrenia, PTSD, or major depression. |
10/01/2016
|
Present
|
92 |
Dwarfism. |
10/01/2016
|
Present
|
93 |
Significant disfigurement, for example, disfigurements caused by burns, wounds, accidents, or congenital disorders. |
10/01/2016
|
Present
|
94 |
Learning disability or attention deficit/hyperactivity disorder (ADD/ADHD). |
10/01/2016
|
Present
|
95 |
Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome, colitis, celiac disease, dysphexia. |
10/01/2016
|
Present
|
96 |
Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis |
10/01/2016
|
Present
|
97 |
Liver disease, for example, hepatitis or cirrhosis. |
10/01/2016
|
Present
|
98 |
History of alcoholism or history of drug addiction (but not currently using illegal drugs). |
10/01/2016
|
Present
|
99 |
Endocrine disorder, for example, thyroid dysfunction |
10/01/2016
|
Present
|