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.


B

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

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

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

Korean descent)
S



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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