Luther Burbank School District

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Luther Burbank School District

Employee/Applicant Identification Form
Section 1233 of the California Government Code permits School districts to solicit from employees a VOLUNTARY declaration of their sex and racial group membership. Information provided will assist the district in accurately compiling required statistical reports for federal and state agencies. A separate, confidential file will be established for these forms and none of the information will be used to discriminate against or give preference to any individual in any personnel transaction.


Desired Position:________________________________________________
Full time / Part Time Male / Female

(Circle one) (Circle one)

Check only one applicable category below. If more than one applies, choose the one category which

best identifies your racial/ethnic background.


lack (Negro, Afro-American, African Filipino (Filipino-An~erican and

descent, Trindadian, Jamaican, West Indian) Filipino descent)

sian (Asian-American, Japanese, Chinese or Native American (American Indian)

Korean descent)

panish/Latino (Chicano, Mexican, Puerto Other (Alcut, Eskimo, Malayan, Thai,

Rican, Latin American or Spanish descent) other nonwhite not specified above)

White (White, Anglo, Pakistani, East DECLINE TO STATE

Indian, Indo-European descent)

Language Ability:

Converse In_____________________________________
Fluent In_______________________________________
Reading Comprehension In________________________

If you are physically handicapped check all applicable categories.

____ Hearing (50% or more loss of hearing in both ears)

____ Speech

____ Sight (use of eyeglasses does not apply)

____ Impairment (Due to amputation, loss of functions, loss of coordination)

____ Other (please specify)

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