Uh Eeo/aa Form 17a - University Of Hawai'I - Civil Service Selection Form
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CIVIL SERVICE SELECTION FORM 17A
This form is required for all civil service employees (except emergency and exempt appointments). The data is used to prepare
federally-mandated reports. Instructions are attached.
1.
Name of Selectee: ____________________________________________ Sex: _____ Ethnicity: ___________________
Last
First
M.I.
Department: __________________________________ Campus: ____________________________________________
Position Title: __________________________________ Position No. ________________ SR/WB: _______________
FTE: _________ Appointment Period: __________________ to _________________ Source of Funding: __________
For Community Colleges, indicate Job Group: ______________________________________________________________
2.
a) [ ] Temporary Appointment or [ ] Permanent Appointment
b) [ ] New Hire or [ ] Transfer or [ ] Promotion
If Transfer or Promotion, indicate below the position selectee is leaving:
Position Title: _____________________________ SR/WB: ________________
[ ]Temporary or [ ] Permanent
Agency/Department: _______________________ Campus: ______________________________________________
3.
Total No. of Applicants: ________ Total No. of Female Applicants: _______ Total No. of Male Applicants: _______
No. Female Applicants: W ___ B ___ Hisp ___ NA ___ API: J ___ C ___ K ___ F ___ H/PH ___ S ___
I ___ O ___ (specify: ______________________________________________________________)
No. Male Applicants: W ___ B ___ Hisp ___ NA ___ API: J ___ C ___ K ___ F ___ H/PH ___ S ___
I ___ O ___ (specify: _______________________________________________________________)
4.
Are women or minorities underutilized (U**) for this position? If yes, specify groups(s): __________________________
I have reviewed this action from an EEO/AA perspective and certify as follows (check if “yes”):
[ ] EEO/AA status improved. Specify underutilized (U**) group(s): __________________________________________
[ ] No EEO/AA improvement: reason for lack of improvement: ______________________________________________
[ ] No underutilized group
_____________________________________ ___________________________________ ______________________
Signature of Reviewing Official
Print Name
Date
_____________________________________ ___________________________________ _______________________
Signature of EEO/AA Designee (if applicable) Print Name
Date
_____________________________________ ____________________________________ ______________________
Signature of Provost, Dean, or Director
Print Name
Date
(if other than Reviewing Official)
UH EEO/AA Form 17A (revised 11/99)
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