Voluntary Survey

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  • THE COMPLETION OF THE INFORMATION BELOW IS VOLUNTARY

    The Lutheran Home will not discriminate against any employee or applicant for employment because of race, color, creed, religion, national origin, sex, disability, veteran status, genetic information, age, marital status, status with regard to public assistance, or any other protected classification.

    In an effort to comply with requirements regarding government record keeping, reporting, and other legal obligations which may apply, we invite you to complete this application data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.

    Please be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

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  • The Lutheran Home Association is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:

    • A “disabled veteran” is one of the following:
      • A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
      • A person who was discharged or released from active duty because of a service-connected disability.
    • A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
    • An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
    • An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

    Protected veterans may have additional rights under USERRA – the Uniformed Services Employment and Reemployment Rights Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service (VETS), toll-free, at 1-866-4-USA-DOL.

    If you believe you belong to any of the categories of protected veterans listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of outreach and positive recruitment efforts we undertake pursuant to VEVRAA.

    Submission of this information is voluntary and refusal to provide it will not subject you to adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended.

    The information you submit will be kept confidential, expect that (a) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (b) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (c) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed.

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  • Form CC-305
    OMB Control Number 1250-0005
    Expires 4/30/2026

    Why are you being asked to complete this form?

    Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

    If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

    How do I know if I have a disability?

    You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

    Disabilities include, but are not limited to:

    • Alcohol or other substance use disorder (not currently using drugs illegally)
    • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
    • Blind or low vision
    • Cancer (past or present)
    • Cardiovascular or heart disease
    • Celiac disease
    • Cerebral palsy
    • Deaf or serious difficulty hearing
    • Diabetes
    • Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
    • Epilepsy or other seizure disorder
    • Gastrointestinal disorders, for example, Crohn’s Disease, irritable bowel syndrome
    • Intellectual or developmental disability
    • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
    • Missing limbs or partially missing limbs
    • Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
    • Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
    • Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
    • Partial or complete paralysis (any cause)
    • Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
    • Short stature (dwarfism)
    • Traumatic brain injury
    Please check one response