DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Equal Opportunity Applicant Data Form
Please Print – Do Not Alter Form
| Name of Program/Facility |
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Date Form Completed |
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| Name of Unit |
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| Form Completed By |
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Name |
Title |
Phone # |
| Vacancy/Classification Title (print in full) |
|
PIN# |
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| Management Service |
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Skilled/Professional |
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Special Appointment |
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Executive Service |
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| Total # Applications Received |
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Total # Applicants Interviewed |
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Race |
Total# by Sex |
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Race |
Total# by Sex |
| M |
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F |
M |
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F |
| 1 |
White |
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/ |
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1 |
White |
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/ |
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| 2 |
Black/African American |
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/ |
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2 |
Black/African American |
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/ |
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| 3 |
Amer Indian/Alaska Native |
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/ |
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3 |
Amer Indian/Alaska Native |
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/ |
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| 4 |
Asian |
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/ |
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4 |
Asian |
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/ |
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| 5 |
Native Hawaiian/Other Pacific |
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/ |
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5 |
Native Hawaiian/Other Pacific |
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/ |
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| 6 |
No Race Checked |
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/ |
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6 |
No Race Checked |
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/ |
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| 7 |
Multi Racial |
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/ |
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7 |
Multi Racial |
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/ |
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| 8 |
Race/Sex Unknown |
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8 |
Race/Sex Unknown |
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| 9 |
Ethnicity: Hispanic or Latino |
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/ |
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9 |
Ethnicity: Hispanic or Latino |
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/ |
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| Selected Applicant |
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Recruitment Source(s) |
| Name |
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o |
Eligible List |
o |
DHMH Limited Job Flyer |
| Race |
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Sex |
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Age |
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o |
Open Job Flyer |
o |
Posting (attach copy) |
| Grade/Step |
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o |
Newspaper Ad |
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| Hispanic or Latino? |
Y |
N |
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Newspaper Name |
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| Screening Method(s) – Check all that apply |
| o |
DHMH Test |
o |
Screen Com/Panel Interview |
o |
Reference Check |
| o |
DBM Test |
o |
Hiring Mgr/Supr Interview |
o |
Other (explain on back) |
| Names of Panel Members |
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Race |
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Sex |
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Briefed? |
The EEO Risk Management Briefing is mandatory. Panel must be diverse and have at least three members. |
| 1. |
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Y/N |
| 2. |
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Y/N |
| 3. |
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Y/N |
| 4. |
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Y/N |
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| Personnel Officer |
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Date |
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Telephone Number |
