Form 168a - Equal Employment Opportunity Commission Elementary-Secondary Staff Information - Sample - 2004

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FORM APPROVED BY OMB
NO. 3046-0003 APPROVAL EXPIRES
EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
12/31/2004
ELEMENTARY-SECONDARY STAFF INFORMATION (EEO-5)
This is a joint requirement of EEOC, and
the Office for Civil Rights and National
Center for Education Statistics of the
Public school systems
Department of Education.
DO NOT ALTER INFORMATION PRINTED IN THIS BOX
NOTE: ALL EMPLOYEES IN YOUR SCHOOL DISTRICT MUST BE INCLUDED ON THIS FORM. Additional Copies of this
form may be obtained from the address below. Send your full report (the original and one copy of this form) to:
PART 1. IDENTIFICATION
PART A. TYPE OF AGENCY WHICH OPERATES THE REPORTING SCHOOL SYSTEM
 Local Public School System
 Special or Regional Agency
 State Education Agency
 Other (Specify)________________________________
B. SCHOOL SYSTEM IDENTIFICATION (OMIT IF SAME AS LABEL)
NAME
STREET AND NO. OR POST OFFICE BOX
CITY/TOWN
COUNTY
STATE
ZIP
C. GENERAL STATISTICS
NUMBER OF SCHOOLS OPERATED
NUMBER OF ANNEXES OPERATED
OCTOBER 1ST ENROLLMENT
D. REMARKS
AUTHORIZATION
THE NATIONAL CENTER FOR EDUCATION STATISTICS WILL PUBLISH INFORMATION APPEARING IN PART II, TOTAL
COLUMN “A” UNLESS THE DISTRICT SPECIFICALLY WITHHOLDS AUTHORITY TO DO SO. IF THE DISTRICT WISHES
TO WITHHOLD SUCH AUTHORITY, CHECK HERE.
AUTHORITY WITHHELD
EEOC-ORIGINAL
EOC FORM 168A
PAGE 1
April 96

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