Civil Service 55B Form – Fill Out and Use This PDF

Mailing Address: No., Street, Apt., or P.O. Box:

What counties are you willing to work in:

Present Employer:

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION

The information which you are providing on this application is being requested pursuant to Sections 55-b and 55-c and Section 50 (3) of the Civil Service Law for the principal purpose of determining the eligibility of applicants to participate in these programs. This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly paragraphs (b), (e), and (f) of such Law. Failure to provide this information may result in an inability to process your application. This information will be maintained at the New York State Department of Civil Service, Albany, New York 12239. For further information, relating only to the Personal Privacy Protection Law, call (518) 457-9375.

ELIGIBILITY FOR EMPLOYMENT

You must be legally eligible to work in the United States at time of appointment and throughout your employment with New York State. If appointed, you must produce documents that establish your identity and eligibility to work in the United States, as required by the Federal Immigration Reform and Control Act of 1986, and the Immigration and Nationality Act.

I affirm under penalties of perjury that all statements made on this application (including any attached papers) are true. I understand that all statements made by me in connection with this application are subject to investigation and verification and that a material misstatement or fraud may disqualify me from appointment and/or lead to revocation of my appointment.

It is the policy of the State of New York to provide for and promote equal opportunity employment, compensation, and other terms and conditions of employment without unlawful discrimination on the basis of age, race, color, creed/religion, disability, national origin, sex/gender, sexual orientation, veteran or military service member status, familial status, marital status, domestic violence victim status, genetic predisposition or carrier status, arrest and/or criminal conviction record, or any other category protected by law, unless based upon a bona fide occupational qualification or other exception.

It is the policy of the New York State Department of Civil Service to provide all qualified persons with equal opportunity in employment and to participate in and receive all the benefits, services, programs and activities of the Department. Reasonable accommodations will be provided to persons with disabilities and those engaged in a religious observance or practice, as are necessary to provide such equal opportunity, including but not limited to, reasonable accommodations in the examination process.

DPM-1 (2/2021 L)

CONFIDENTIAL MEDICAL STATEMENT OF DISABILITY:

Placement pursuant to Sections 55-b and 55-c of the Civil Service Law is limited to persons with physical or mental disabilities, but who are found otherwise qualified to perform satisfactorily the duties of a position.

It is the responsibility of the applicant to provide medical documentation in support of his or her application. Accordingly, applicants are required to submit Form DPM-60, which is to be completed, signed and dated, by his or her physician. A copy of Form DPM-60 is attached to this application. Candidates may be requested to provide additional medical documentation to determine eligibility, if needed.

Veterans with a disability rating of 10% or more from the VA may send a copy of your VA Rating Decision Letter in lieu of Form DPM-60. The letter must include both the rating and the diagnosis of your disability.

If you have a learning disability, you must submit a copy of your most recent psychological testing, in lieu of Form DPM-60.

If you are legally blind, you may submit a certificate of legal blindness, in lieu of Form DPM-60.

Your application will not be processed until the proper medical documentation is received. The medical documentation will be evaluated by a physician of the Employee Health Service. Medical information will be kept confidential.

SERVICE IN THE ARMED FORCES OF THE UNITED STATES:

DPM-1 (2/2021 L)

Documentation submitted to establish your medical eligibility for appointment consideration under Sections 55-b/c of the Civil Service Law must be current and must include the following information.

Please have your Physician complete this Questionnaire.

In some cases, you may need to attach additional documentation.

If you have questions or concerns, we can be reached at

518-473-8961 or toll-free at 1-866-297-4356.

2) A short summary of applicant’s case history:

2a) Please indicate if disability is connected with applicant’s service in the US Armed Forces: :

3)Current treatment (including medications, therapy, prosthetics):

4)Prognosis (Please indicate if impairment is permanent, long term, and/or if applicant is expected to recover fully:

5)How does the impairment(s) limit the applicant’s major life activities? (Major life activities include

activities such as caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. Major life activities also include major bodily functions such as immune system functions, normal cell growth, digestive, bowel,

bladder, neurological, brain, respiratory, circulatory, and endocrine functions. If there are other life activities, which the applicant’s disabilities limit, please note.)

Date:

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Medical Provider