| Document Date: 2014-03-07 23:15:51
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MedicalCondition leukemia / respiratory disorders / cerebral palsy / Pulmonary / COMPLETE PARALYSIS / Mental retardation / gunshot injuries / kyphosis / Cancer / chronic and lifelong condition / aphasia / palsy / disorder / Convulsive disorder / Total deafness / Blood diseases / chronic pain / burns / epilepsy / dyslexia / Learning disability / emphysema / sickle cell anemia / PARTIAL PARALYSIS / birth defects / emotional illness / hemophilia / Heart disease / Diabetes / dwarfism / tuberculosis / stuttering / asthma / / MedicalTreatment dialysis / / Organization U.S. office of Personnel Management FPM Supplement / State Vocational Rehabilitation / / Position personnel officer / / Technology dialysis / /
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SELF-IDENTIFICATION OF HANDICAP (See instructions and Privacy Act information on reverse) Last Name, First Name, Middle Initial Birth Date (Mo/Yr)