Affirmative Action Survey
St. Luke's Lutheran Care Center is a government contractor, subject to governmental regulations and affirmative action responsibilities. Applicants are considered for positions for which they apply and employees are treated during employment without regard to race, color religion, creed, gender, marital status, national origin, sexual orientation, age, disability, status as a disabled or Vietnam-era veteran, status with regard to public assistance, or other protected class.

To assist with the required record keeping, reporting and other legal requirements; please fill out this confidential survey. This survey will be immediately separated from your application and kept in a separate confidential file and will be used only for governmental reporting purposes.

Providing this information is voluntary and refusal to provide this information will in no way affect your status as an applicant

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Name:
Date Applied:
 Position Applied For: Other  
Applying for:  Full Time:   Part Time: On-Call: Check One:  Male Female
Referral Source:
Job Service St. Luke's Website Other:
Employee Referral Newspaper Ad Radio Ad
Name: Name: Name:
Select one or more:      
Black/African American American Indian/Alaskan Native Asian More than one race
Native Hawaiian/Pacific Islander Hispanic/Latino White  

Check if any of the following apply to you:

Are you a person with a disability? Yes      No

  • Have a physical or mental impairment which substantially limits one or more of person's life activities
  • Have a record of such impairment
  • Regarded as having such impairment
Are you a Vietnam-era veteran? Yes      No
  • Served more than 180 days in active military, naval or air service any part of which was from August 5, 1964 through May 7, 1975, and discharge or release from active duty was because of a service-connected disability or for other than dishonorable discharge, or if any part of such active duty occurred in the Republic of Vietnam between February 28, 1961 and May 8, 1975.

Are you a disabled veteran? Yes      No

  • Entitled to compensation from the Veterans Administration for a disability rated 30% or more or rated at 10-20% for a veteran determined to have a serious employment handicap or

  • Discharged or released from active duty because of a service-connected disability