2011 Request For Proposal Cover Sheet Template Page 9
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11STATE OF CONNECTICUT, Department of Public Health RFP # 2011-0917; Tobacco Use Cessation Services
APPLICATION FORMS
WORKFORCE ANALYSIS
Contractor Name:
Total Number of CT employees:
Address:
Full Time:
Part Time:
Complete the following Workforce Analysis for employees on Connecticut worksites who are:
Job
Overall
White
Black
Hispanic
Asian or Pacific
American
People with
Categories
Totals
(Not of Hispanic
(Not of Hispanic
Islander
Indian or
Disabilities
(Sum of
Origin)
Origin)
Alaskan Native
all cols.
male &
female)
Male
Femal
Male
Female
Male
Female Male
Femal
Male
Femal
Male
Female
e
e
e
Officials &
Managers
Professionals
Technicians
Office &
Clerical
Craft Workers
(Skilled)
Operatives
(Semi-skilled)
Laborers
(Unskilled)
Service Workers
Totals Above
Totals 1 year Ago
FORMAL ON-THE-JOB TRAINEES (Enter figures for the same categories as are shown above)
Apprentices
Trainees
Employment
EMPLOYMENT FIGURES WERE OBTAINED FROM:
Visual Check:
Records
Other:
1. Have you successfully implemented an Affirmative Action Plan?
YES
NO
Date of implementation:__________________If the answer is “No”, explain.
1. a) Do you promise to develop and implement a successful Affirmative Action?
YES
NO
Not Applicable
Explanation:
2. Have you successfully developed an apprenticeship program complying with Sec. 46a-68-1 to 46a-68-18 of the Connecticut
Department of Labor Regulations, inclusive:
YES
NO
Not Applicable
Explanation:
3. According to EEO-1 data, is the composition of your work force at or near parity when compared with the racial and sexual composition
of the work force in the relevant labor market area?
YES
NO
Explanation:
4. If you plan to subcontract, will you set aside a portion of the contract for legitimate minority business enterprises?
YES
NO
Explanation:
____________________________________
________________________
Contractor’s Authorized Signature
Date
RFP # 2011-0917 APPLICATION FORMS
Page 9 of 11
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