Instructions For Completing And Submitting The State Of Connecticut Application For Examination Or Employment (Form Ct-Hr-12) (Fillible) Page 11
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12PAGE TEN
________________________________________
_______________________ ____
Last Name
First Name
MI
______________________________________________________________________
Examination Title or Position Title
SECTION 11: TESTING ACCOMMODATIONS FOR EXAMINATIONS
Qualified individuals with a disability may request special testing accommodations under
provisions of the Americans with Disabilities Act (ADA) by contacting DAS Statewide Human
Resources at 860-713-5206 (voice) and at 860-713-7463 (TDD) immediately upon submitting an
application for this examination. Provide your name, exam title and number, a description of
your specific needs and documentation from a health care provider verifying your disability.
SECTION 12: VOLUNTARY
In order to meet State and Federal reporting requirements, we are requesting that you voluntarily
supply the following information. This data will not be considered in the evaluation of your
application.
A. SEX:
___ Female
___ Male
B. RACE/ETHNIC DATA:
__ 1 AMERICAN INDIAN OR ALASKAN NATIVE: Persons having origins in any of the original
peoples of North America, and who maintain cultural identification through tribal affiliation or
community recognition.
__ 2 ASIAN/ PACIFIC ISLANDER: Persons having origins in any of the original peoples of the Far
East, Southeast Asia the Indian Subcontinent or the Pacific Islands. This area includes, for
example, China, Japan, Korea, the Philippine Islands, and Samoa.
__ 3 BLACK/AFRICAN-AMERICAN (NOT OF HISPANIC ORIGIN): Persons having origins in any
of the black racial groups of Africa.
__ 4 HISPANIC: Persons of Mexican, Puerto Rican, Central or South American or other Spanish
culture or origin, regardless of race.
__ 5 WHITE (NOT OF HISPANIC ORIGIN): Persons having origins in any of the original peoples of
Europe, North Africa, or the Middle East.
C. PRIMARY SOURCE OF EXAM/JOB INFORMATION:
Where did you learn about this exam or job/position? (Check and complete below.)
__ 1
State of Connecticut Internet site. Website: _______________________________________
__ 2
Other Internet Site. Website: __________________________________________________
__ 3
Newspaper, professional journal, radio or TV advertisement.
Please give the name of the publication/station, etc: _________________________________
__ 4
Paper Posting
__ 5
Direct e-mail or paper mailing.
__ 6
Career fair. Event/Location: ____________________________________________________
__ 7
Other. Please specify: ________________________________________________________
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