(SHORT FORM)
SAMPLE
UNIVERSITY OF PENNSYLVANIA
FACULTY EQUAL OPPORTUNITY COMPLIANCE STATEMENT
TO:
RE:
THE PROVOST
APPOINTMENT
Proposed Academic Class/Category: (Check class and category )
Standing Faculty (check below)
Tenured
Tenure Track
Non-Tenured (Clinician-Educator)
School:
Associated Faculty
Academic Support Staff
Lecturers (all classification except “C”)
Artist-in-Residence
Instructor
Research Associate
Clinical Associate
Research Faculty
Academic Clinician
Clinical Faculty
Practice Professor
Wistar
Medicine
Department:
Orthosurgery
Name of Candidate:
Furqan Haq
Sex:
Ethnicity:
2 (M)
2 (Asian)
(insert numeric codes for sex and ethnicity – see page 3)
Present Title:
NONE
Is the candidate currently employed at the University of Pennsylvania:
Proposed
Title:
No
Yes
Research Associate
Proposed Date of Appointment:
7/1/2010
RECOMMENDATION IN THE ABSENCE OF A SEARCH

Target of Opportunity in the following faculty classes only: Standing Faculty, Standing Faculty--Clinician-Educator
Only in rare and exceptional instances is it possible to make an appointment without a search. This exception is possible only when a
person of unquestioned preeminence becomes available and the University can justify the appointment. In such cases, briefly
summarize why it is believed that this recommendation warrants special consideration.
(REQUIRED – A full explanation is required. Attach supplemental information.)
I.
SUMMARY OF DEPARTMENTAL ACTION FOR APPOINTMENT
SEARCH PROCESS
1.
Where did you advertise (e.g., professional journals, on-line, caucus newsletters, newspapers)? [Submit at least two advertisements
along with dates of publication for Standing Faculty (Tenure and Clinician-Educator), Research track and Academic Clinicians in
the Associated Faculty. Submit at least one advertisement along with date(s) of publication for all other classes in the Associated
Faculty and Academic Support Staff.]
Post Ad on FAPD website-Attach Ad
2.
List those professional minority and women’s organizations you consulted with regard to this search.
3.
If you contacted universities, schools, and departments, attach a list.NA
4.
Submit a sample letter used to make these contacts. The letter should show that schools and departments were encouraged to
submit the names of women and minority persons. NA
5.
List the women and minority scholars whose help you have solicited in filling this position. NA
Rev. November 2006
NA
[BLUE]
(SHORT FORM)
UNIVERSITY OF PENNSYLVANIA
FACULTY EQUAL OPPORTUNITY COMPLIANCE STATEMENT
II.
THE CANDIDATE POOL
Make sure this grid matches the numbers
on the Recruitment Worksheet ---
1. NOTE: Departments are required to maintain all applications on file for three years
Total
All
Total
Female
Total
Minority
a)
Number of persons considered via applications, referrals, dossiers on file,
telephone, video conference, conference, etc.
2
0
2
b)
Number of persons interviewed
2
0
2
c)
Number of persons invited for an interview but declined
0
0
0
Total
Unknown
0
2. Candidate and Applicant Data
a) Indicate the racial and gender categories of the proposed candidate and applicant(s) interviewed
(Insert numeric code 1 – 5; see categories and definitions on page 3). Attach additional page(s), if necessary.
Name
Recommended Applicant:
 Furqan Haq
Sex
Race
Interview
Method
2 (M)
2
Asian
3
Reason(s) not
Recommended *
Other Applicant(s) Interviewed:
 ATTACH RECRUITMENT WORKSHEET
 Download the Worksheet directly from MyDotMed, see section for
 "Faculty Ad Applicants Review"
b) If there is only one applicant listed and/or the candidate is an internal hire, please provide justification in the comment section
below. See codes and definitions on page 3.
3.
Attach a CV of the Candidate (SOM John Doe CV format NOT Required )
4.
If the candidate is neither minority nor female, submit the dossiers (curriculum vitae and recommendation letters) of the two most
qualified members of minority groups and the two most qualified women considered.
Name of Candidate
Sex
If yes, please list the names below. Include the race and gender codes for each candidate.
NA
NA
5.
Race
Describe the reasons for selecting the proposed candidate. If minority or female candidates were considered and not chosen,
indicate specifically why the candidate was deemed the most qualified over the best minority and female candidates.
Describe the candidate's scientific research expertise or clinical expertise >>>>>> Dr Haq has experience in the area of
RNA1 and investigations of cell signaling pathways. ( Use one or two sentences only)
Comment(s):
Describe reason for or purpose of position>>>>>Indicate if candidate will be getting additional training in this position.
or will developmore independence in research, or has KAward for Career Development , or is providing clinical support
to department . ( Use one or two sentences only)
III.
CERTIFICATION OF COMPLIANCE
All persons signing this compliance form attest that a good faith effort was made to conduct the search and selection process for this position
in compliance with relevant University policies and procedures pertaining to filling vacancies and equal opportunity/affirmative action.
Do not send to AA Officer – Attach to Offer
Letter /RTR for submission to FAPD
Get Department Chair Signature
Department Chair/Hiring Officer
Date
AA Compliance Officer
Date
Dean or Dean’s Representative
Date
Provost or Provost’s Representative
Date
Rev. November 2006
Page 2 of 6
(SHORT FORM)
UNIVERSITY OF PENNSYLVANIA
FACULTY EQUAL OPPORTUNITY COMPLIANCE STATEMENT
The concept of race as used by the Office of Federal Contract Compliance Programs (O.F.C.C.P.) and the Equal Employment
Opportunity Commission (E.E.O.C.) does not denote clear-cut scientific definitions of anthropological origins. Nevertheless, each
employee or candidate must be identified as belonging to one, and only one, of five broad racial/ethnic categories defined by federal
authorities. A candidate may be included in the group to which he or she appears to belong, identifies with, or is regarded in the
community as belonging.
FEDERAL RACE AND ETHNICITY DEFINITIONS
The categories for data on race and ethnicity for Federal statistics and civil rights compliance are defined as follows:
1.
Black (not of Hispanic origin): A person having origins in any of the black racial groups of Africa (except those of Hispanic origin)
2.
Asian/Pacific Islander: A person with origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent or
the Pacific Islands. This includes people from China, Japan, Korea, the Philippine Islands, American Samoa, India, and Vietnam.
3.
White (not of Hispanic origin):
(except those of Hispanic origin).
4.
Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
5.
American Indian/Alaskan Native: A person having origins in any of the original peoples of North America or who maintains cultural
identification through tribal affiliation or community recognition.
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
SEX
1.
2.
Female
Male
INTERVIEW METHOD
1.
2.
3.
Interviewed by telephone
Interviewed by video conference
Interviewed in person
REASON NOT RECOMMENDED
1.
2.
3.
4.
5.
6.
7.
8.
9.
Previous experience not as strong
Did not possess preferred educational level
Position related skills not as strong
Applicant salary requirement too high
Applicant did not show for interview
Applicant interviewed withdrew from consideration
Applicant rejected offer
Applicant decline interview
Other (note reason in the additional comment section on page two)
REASON ONLY 1 APPLICANT INTERVIEWED
1.
2.
3.
Other applicants lacked specific position knowledge/experience
Other (note reason in the additional comment section on page two)
Waiver has been granted (summarize reason in the recommendation in the absence of a search section on page one AND record
reason code under the Candidate and Applicant Data section, in the reason(s) not recommended column on page two)
 [See Affirmative Action Guidelines for Target of Opportunity]
Rev. November 2006
Page 3 of 6
(SHORT FORM)
FAPD AD POSTING
Research Associate
Posting Department: Orthopaedic Surgery
State: posted
Posted Date: 07/08/2008
Expire Date: 07/08/2010
OFFICIAL AD TEXT:
The Department of Orthopaedic Surgery at the University of Pennsylvania School of Medicine seeks candidates for a
Research Associate position in the Academic Support Staff. This appointment will be initially for one (1) year and
continuation during that time period and renewal are based on satisfactory performance and availability of funding
(limited to three (3) years). Applicants must have an Ph.D. or M.D./Ph.D. degree and have demonstrated excellent
qualifications in Research.
The successful applicant will have experience in the area of RNA1 and investigations of cell signaling pathways. Projects
will investigate human disorders of heteroptopic ossification such as fibrodysplasia ossificans progressive (FOP) and
progressive osseous heteroplasia (POH).
The University of Pennsylvania is an equal opportunity, affirmative action employer. Women and minority candidates are
strongly encouraged to apply.
Apply for this position online at: http://www.med.upenn.edu/apps/faculty_ad/index.php/g328/d1686
Rev. November 2006
Page 4 of 6
(SHORT FORM)
ATTACH CV OF CANDIDATE
(Not required to be in John Doe Format)
Rev. November 2006
Page 5 of 6
(SHORT FORM)
Recruitment
Worksheet
UNIVERSITY OF
PENNSYLVANIA
SCHOOL OF
MEDICINE
DEPARTMENT OF
Orthopaedic
Surgery
Ad Title:
Research_Associate
Proposed Rank:
Research Associate
Search
Committee Chair:
NOT
REQUIRED
FOR SHORT
AA FORM
Search
Committee
Members:
NOT
REQUIRED
FOR SHORT
AA FORM
Proposed Track:
POSTED 7/8/2010
For Gender and Ethnicity, this information
MUST be entered by the applicant in the online
application process. The staff member filling
in the form should not enter or edit Gender
and Ethnicity.
Candidate Name
Intern
al
Candi
date
Gend
er
1
Furqan Haq
M
2
venkata malakapalli
M
Ethni
city
Asian
/Pacif
ic
Islan
der
Asian
/Pacif
ic
Islan
der
Recrui
ter's
Action
Date CV
Received
Letter(
s)
Recei
ved
sourc
e of
initial
conta
ct
info gathered via
phone or e-mail
references
contacted
candidate
interview
ed
Reason
Recomme
nded /OR
NOT
Recomme
nded
Applican
t
Source(
s)
1/9/2010
websit
e
website
1/10/2010
websit
e
other_fa
c
DATE PRINTED
Rev. November 2006
inter
view
Date
Why
did
can
dida
te
with
dra
w or
elect
not
to
com
e to
Pen
n?
Page 6 of 6