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DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Equal Opportunity Applicant Data Form
 
Please Print – Do Not Alter Form
Name of Program/Facility
 
Date Form Completed
 
Name of Unit
 
Form Completed By
 
 
Name
Title
Phone #
Vacancy/Classification Title (print in full)
 
PIN#
 
Management Service
 
 
Skilled/Professional
 
 
Special Appointment
 
 
Executive Service
 
 
 
Total # Applications Received
 
 
 
Total # Applicants Interviewed
 
 
Race
Total# by Sex
 
 
Race
Total# by Sex
M
 
F
M
 
F
1
White
 
/
 
 
1
White
 
/
 
2
Black/African American
 
/
 
 
2
Black/African American
 
/
 
3
Amer Indian/Alaska Native
 
/
 
 
3
Amer Indian/Alaska Native
 
/
 
4
Asian
 
/
 
 
4
Asian
 
/
 
5
Native Hawaiian/Other Pacific
 
/
 
 
5
Native Hawaiian/Other Pacific
 
/
 
6
No Race Checked
 
/
 
 
6
No Race Checked
 
/
 
7
Multi Racial
 
/
 
 
7
Multi Racial
 
/
 
8
Race/Sex Unknown
 
 
8
Race/Sex Unknown
 
9
Ethnicity:  Hispanic or Latino
 
/
 
 
9
Ethnicity:  Hispanic or Latino
 
/
 
 
Selected Applicant
 
Recruitment Source(s)
Name
 
 
o
Eligible List
o
DHMH Limited Job Flyer
Race
 
Sex
 
Age
 
 
o
Open Job Flyer
o
Posting (attach copy)
Grade/Step
 
 
 
o
Newspaper Ad
 
Hispanic or Latino?
Y
N
 
Newspaper Name
 
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
 
Race
 
Sex
 
Briefed?
The EEO Risk Management Briefing is mandatory.  Panel must be diverse and have at least three members.
1.
 
 
 
 
 
 
Y/N
2.
 
 
 
 
 
 
Y/N
3.
 
 
 
 
 
 
Y/N
4.
 
 
 
 
 
 
Y/N
 
 
 
 
 
Personnel Officer
 
Date
 
Telephone Number
Rev. 1/07