Printed 4/8/2008 DHR-19
Section I (To be completed by designated agency personnel)
Name of Agency Department of Transportation IDHR Region
Facility/Unit Candidate’s Name
Title of Job to be filled Pay Grade
Number to be filled Position Number
EEO Job Category Employment Date
1. Is this EEO Category underutilized? Yes No If yes, by which of the following:
African-Americans Hispanics Women Asians Native Americans Disabled
2. Indicate: Sex of person(s) selected
Race of person(s) selected
Veteran or non-Veteran
Disability, if any
3. Number of individuals who applied or were on the list of eligible(s)
were African American, invited, interviewed, selected
were Hispanic, invited, interviewed, selected
were Women, invited, interviewed, selected
were Asian, invited, interviewed, selected
were Native American, invited, interviewed, selected
were Veterans, invited, interviewed, selected
were Disabled, invited, interviewed, selected
were Undefined, invited, interviewed, selected
4. If no candidates from any of the underutilized groups appeared on the list, what efforts were made in the last six
months to assist in the recruitment of candidates?
5. If the category is underutilized and a member of an affirmative action group applied and was not hired give a detailed
explanation for the hiring decision.
6. Was the position posted?
7. Name and position of person(s) who interviewed candidates.
8. Name and position of person(s) who recommended the selection of the candidate.
Scott Doubet, Bureau Chief of Personnel Management
Section II (To be signed by agency EEO/AA Officer and Chief Executive Officer or their designees)
I have reviewed the eligibility list and concur / do not concur with this hire. Remarks on reverse side.
EEO/AA Officer Date
I approve of this hire.
Chief Executive Officer Date
No appointment will be processed without this form. [DHR Rules and Regulations Section 2520.770(i)]
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