EXHIBIT B
Procedure 02-02-15
May 12, 2009
Office of Affirmative Action, Diversity, and Inclusion
University of Pittsburgh
412 Bellefield Hall, 315 S. Bellefield Avenue
Pittsburgh, PA 15260
UNIVERSITY OF PITTSBURGH
EQUAL EMPLOYMENT OPPORTUNITY INFORMATION REQUEST
TO THE DEPARTMENT:
Please TYPE the information needed on the top portion of this form BEFORE mailing it to the applicant.
Department __________________
Position Number ____________________
Name of Applicant ______________________________________________________________________
(Last)
(First)
(M.I.)
Title/Rank of Position Applied For _________________________________________________________
Date Application Received in Department Office ______________________________________________
Name of Department _____________________________________________________________________
**************************************************************************************
TO THE APPLICANT:
The University of Pittsburgh is required by Federal law to request and maintain data on the racial/ethnic
and sex identity of all applicants for employment. These data provide the University of Pittsburgh and the Federal
government with information necessary to monitor the University’s compliance with equal employment opportunity
requirements.
Please complete this form and return it directly to the Office of Affirmative Action, Diversity and Inclusion
in the enclosed addressed envelope. Submission of the information requested is voluntary, and failure to provide it
will not subject you to adverse treatment. Note: This form will not be kept with your application. Additional
application materials should not be sent with this form, but sent directly to the department to which you have
applied.
SEX: _______________FEMALE
_______________MALE
Are you Hispanic or Latino?
________Yes
_______No
RACIAL/ETHNIC DATA: Please identify your race and ethnicity by selecting all applicable box(s) below:
________Black or African American– A person having origins in any of the black racial groups of Africa
________Asian– A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam
________American Indian or Alaskan Native– A person having origins in any of the original peoples of North
and South America (including Central America), and who maintain tribal affiliation or community attachment.
________ White – A person having origins in any of the original peoples of Europe, the Middle East, or North
Africa
________Native Hawaiian or Other Pacific Islander– A person having origins in any of the peoples of Hawaii,
Guam, Samoa, or other Pacific Islands
CITIZENSHIP: _____ U.S. Citizen; _____ Non-U.S., Permanent Resident; _____ Non-U.S., Non-Permanent
Resident
HOW DID YOU LEARN OF THIS POSITION OPENING? (Check one)
_____ Professional Conference
_____ Professional Journal --- please specify _________________________________________
_____ Chronicle of Higher Education
_____ External Notice/Posting outside of University of Pittsburgh
_____ Internal University of Pittsburgh Notice/Posting
_____Personal Contact by University of Pittsburgh employee (including referral and nomination)
_____ University Times Jobs Available Listing
_____ Post-Gazette (PG); Pittsburgh Courier (PC) --- please specify_______________________
_____ Other newspaper --- please specify ____________________________________________
_____ On-line/Internet --- please specify _____________________________________________
_____ Other --- please specify _____________________________________________________
Form 0122 – Procedure 02-02-15