DEMOGRAPHIC INFORMATION ON APPLICANTS

1 MORROW COUNTY HEALTH DISTRICT 619 West Marion Road Mount Gilead, Ohio 43338 Phone: (419) 947-1545 Fax: (419) 946-6807 E-mail: Online: DEMOGRAPHIC INFORMATION ON APPLICANTS Open Position Title: _____ Your Privacy Is Protected. This INFORMATION is used to determine if our recruitment efforts are reaching all segments of the population, consistent with Federal equal opportunity laws and affirmative action. We are an organization that values diversity and encourages women and minorities to apply. Your voluntary responses are treated in the highly confidential manner. This is vital INFORMATION , not available from any other source.

2 We can only get it directly from you. Thank you for helping us provide better service. Please complete the INFORMATION below: I do not wish to complete the form. 1. How did you learn about this position? (Check One): Morrow County Health District s website Newspaper Name: _____ Relative Friend Professional Association ( : ONA, OEHA, AOHC, etc.) Morrow County Health District Employee Other Internet Website ( : , , Ohio Means, etc.) Other _____ 2. Gender (Check One): Male Female I:\HR\Employment\ DEMOGRAPHIC Fillable INFORMATION Page 1 3. Veteran (Check One): Yes No 4. Disabled (Check One): Yes No 5. Ethnicity (Check One): Are you Hispanic or Latino?

3 Yes No If you answered Yes you have completed the form. If you answered No please select a race from the options below. 6. Race (Check all that apply): White Black or African American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Two or More Races Privacy Act & Paperwork Reduction Act Statement Privacy Act INFORMATION : This INFORMATION is provided pursuant to Public Law 93-579 ( Privacy Act of 1974 ), for individuals, completing Federal records, and forms that solicit personal INFORMATION . The authority is Title 5 of the Code, sections 1302, 3301, 3304, 7201. Purpose and Routine Uses: No individual data is ever provided to selecting officials.

4 This form will only be seen by HR Personnel and Equal Employment Opportunity officials. Data summarizing all APPLICANTS for a position will be used to determine if we are effectively recruiting from all segments of the population, in conformance with the requirements of Federal equal employment opportunity laws. Only summary data is reported, and only in a format which can not be broken out by individual APPLICANTS . Effects of Nondisclosure: Providing this INFORMATION is voluntary. No individual personnel selections are made based on this INFORMATION . Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 (44 3501 et. seq,) requires us to inform you that this INFORMATION is being collected for planning and assessing affirmative employment program initiatives.

5 Response to this request is voluntary. I:\HR\Employment\ DEMOGRAPHIC Fillable INFORMATION Page 2