Name of Program/Facility
MARYLAND DEPARTMENT OF HEALTH
Equal Opportunity Applicant Data Form
Please Print – Do Not Alter Form
|Name of Program/Facility | |Date Form Completed | |
|Name of Unit | |
|Form Completed By | |
| |Name |Title |Phone # |
|Vacancy/Classification Title (print in full) | |PIN# | |
|Management Service |
| |
|Total # Applications Received | | | |Total # Applicants Interviewed | |
| |Race |Total# by Sex | | |Race |Total# by Sex |
| | |M | |F | | |
|9 |Ethn| |
| |icit| |
| |y: | |
| |Hisp| |
| |anic| |
| |or | |
| |Lati| |
| |no | |
|Name | | |( |Eligible List |( |DHMH Limited Job Flyer |
|Race | |Sex | |Age | | |
|Hispanic or Latino? |Y |N | |Newspaper Name |
|Screening Method(s) – Check all that apply |
|( |DHMH Test |( |Screen Com/Panel Interview |( |Reference Check |
|( |DBM Test |( |Hiring Mgr/Supr Interview |( |Other (explain on back) |
|Names of Panel Members | |Race | |Sex | |Briefed? |The EEO Risk Management Briefing is |
| | | | | | | |mandatory. Panel must be diverse and |
| | | | | | | |have at least three members. |
|1. | | | | | | |Y/N | |
|2. | | | | | | |Y/N | |
|3. | | | | | | |Y/N | |
|4. | | | | | | |Y/N | |
| | | | | |
|Personnel Officer | |Date | |Telephone Number |
Rev. 1/07
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