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    Maryland Department of Health
    OHR

    EEo Applicant

    ​DEPARTMENT OF HEALTH AND MENTAL HYGIENE
    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     Skilled/Professional     Special Appointment     Executive Service  
     
     
    Total # Applications Received       Total # Applicants Interviewed  
      Race Total# by Sex     Race Total# by Sex
    M   F M   F
    1 White   /     1 White   /  
    2 Black/African American   /     2 Black/African American   /  
    3 Amer Indian/Alaska Native   /     3 Amer Indian/Alaska Native   /  
    4 Asian   /     4 Asian   /  
    5 Native Hawaiian/Other Pacific   /     5 Native Hawaiian/Other Pacific   /  
    6 No Race Checked   /     6 No Race Checked   /  
    7 Multi Racial   /     7 Multi Racial   /  
    8 Race/Sex Unknown     8 Race/Sex Unknown  
    9 Ethnicity:  Hispanic or Latino   /     9 Ethnicity:  Hispanic or Latino   /  
     
    Selected Applicant   Recruitment Source(s)
    Name     o Eligible List o DHMH Limited Job Flyer
    Race   Sex   Age     o Open Job Flyer o Posting (attach copy)
    Grade/Step       o Newspaper Ad  
    Hispanic or Latino? Y N   Newspaper Name
     
    Screening Method(s) – Check all that apply
    o DHMH Test o Screen Com/Panel Interview o Reference Check
    o DBM Test o Hiring Mgr/Supr Interview o 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​