Equal Opportunity Assurance Employee Selection Report Form 2007 printable pdf download

Equal Opportunity Assurance Employee Selection Report

(Including Applicant Tracking Information)

This form must be completed (2 pages) by any DDS manager or supervisor who has been authorized to fill a position vacancy. The

form must be completed whether a position is filled via promotion, transfer layoff list or any other employment selection process.

Indicate Region, Southbury Training School or Central Office________________________

Vacancy, Job Title_______________________________ 3. PC#_______________________

Check one: ( ) Permanent

( ) Temporary or Durational

Check one: ( ) Full Time

( ) Part Time

Worksite, Town/City______________________ 7. Start Date:__________________________

Indicate (check one or more below), the affirmative action outreach efforts you initiated:

( ) Utilized, DDS Human Resource (Personnel) Office

( ) Utilized media advertising …Describe________________________________________________

__________________________________________________________________________________

( ) Utilized outside referral resources, e.g., Hispanic community organization, NAACP, college or

university placement office, etc. Describe________________________________________________

_______________________________________________________________________________

( ) Encouraged employees, who are participants in the DDS Upward Mobility Program, to apply for

the available opportunity.

( ) Contacted other supervisors or managers for assistance in identifying employees who are

participants in the DDS Upward Mobility Program.

( ) Identified all ‘Protected Status’ applicants whose names appeared on Employment/Certification

List and sent invitations to interview for vacancy opportunity (applies to competitive vacancies)

( ) Requested assistance from the DDS Equal Opportunity Assurance Division.

( ) Other ‘affirmative action’ initiatives… Describe:________________________________________

__________________________________________________________________________________

( ) Implemented none of the above

Check the underutilized groups/goal identified in Affirmative Action Plan applicable to the vacancy:

( ) White male

( ) White female ( ) Black male

( ) Black female

( ) Hispanic male

( ) Hispanic female

( ) Other male

( ) Other female

10. Name, Job Title and work - phone # of selecting supervisor/manager:

Name _______________________________

Job Title_______________________________ Work Phone_______________

11. List all candidates, considered for the vacancy/opportunity, on the REVERSE SIDE of this form.

FOR ASSISTANCE contact the the Equal Opportunity Assurance Division in Hartford (860 418-6115).

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Equal Opportunity Assurance Employee Selection Report Form 2007