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Appendix A
EEO Report Forms
This appendix reproduces the four equal employment opportunity
(EEO) reports that collect data relevant to wages and employment, dis-
cussed in Chapter 1:
• EEO-1, required from private employers with 100 or more employ-
ees or 50 or more employees and a federal contract;
• EEO-3, required from referral unions, primarily unions with exclu-
sive hiring arrangements with an employer;
• EEO-4, required from state and local governments; and
• EEO-5, required from primary and secondary public school districts.
99
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100 COLLECTING COMPENSATION DATA FROM EMPLOYERS
A-2
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APPENDIX A 101
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102 COLLECTING COMPENSATION DATA FROM EMPLOYERS
A-4
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APPENDIX A 103
A-5
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104 COLLECTING COMPENSATION DATA FROM EMPLOYERS
EQUAL EMPLOYMENT OPPORTUNITY COMMISSION APPROVED BY
OMB
STATE AND LOCAL GOVERNMENT INFORMATION (EEO4) 30460008
EXPIRES
EXCLUDE SCHOOL SYSTEMS AND EDUCATIONAL INSTITUTIONS 12/31/2005
(Read attached instructions prior to completing this form)
DO NOT ALTER INFORMATION PRINTED IN THIS BOX MAIL COMPLETED
FORM TO:
EEO-4 Reporting Center
PO Box 1898
Chicago, IL 60690-1898
A. TYPE OF GOVERNMENT (Check one box only)
1. State 2. County 3. City 4. Township 5. Special District
6. Other (Specify)___________________________________________________________________________
B. IDENTIFICATION
1. NAME OF POLITICAL JURISDICTION (If same as label, skip to Item C)
2. AddressNumber and Street CITY/TOWN COUNTY STATE/ZIP EEOC USE
ONLY
A
B
C. FUNCTION
(Check one box to indicate the function(s) for which this form is being submitted. Data should be reported for all
departments and agencies in your government covered by the function(s) indicated. If you cannot supply the data for
every agency within the function(s) attach a list showing name and address of agencies whose data are not included.)
1.Financial Administration. Tax billing and 8. HEALTH. Provision of public health
collection, budgeting, purchasing, central services, outpatient clinics, visiting nurses,
accounting and similar financial administration food and sanitary inspections, mental health,
carried on by a treasurer's, auditor's or alcohol rehabilitation service, etc.
comptroller's office and
9. HOUSING. Code enforcement, low rent
GENERAL CONTROL. Duties usually performed by public housing, fair housing ordinance
boards of supervisors or commissioners, central enforcement, housing for elderly, housing
administration offices and agencies, central rehabilitation, rent control.
personnel or planning agencies, all judicial offices
and employees (judges, magistrates, bailiffs, etc.)
2. STREETS AND HIGHWAYS. Maintenance, 10. COMMUNITY DEVELOPMENT. Planning,
repair, construction and administration of streets, zoning, land development, open space,
alleys, sidewalks, roads, highways and bridges. beautification, preservation.
3. PUBLIC WELFARE. Maintenance of homes and
11. CORRECTIONS. Jails, reformatories,
other institutions for the needy; administration of
detention homes, halfway houses, prisons,
public assistance. (Hospitals and sanatoriums
parole and probation activities
should be reported as item7.)
4. POLICE PROTECTION. Duties of a police 12. UTILITIES AND TRANSPORTATION.
department sheriff's, constable's, coroner's office, Includes water supply, electric power, transit,
etc., including technical and clerical employees gas, airports, water transportation and
engaged in police activities. terminals.
13. SANITATION AND SEWAGE. Street
5. FIRE PROTECTION. Duties of the uniformed fire cleaning, garbage and refuse collection and
force and clerical employees. (Report any forest disposal. Provision, maintenance and
fire protection activities as item 6.) operation of sanitary and storm sewer
systems and sewage disposal plants.
6. NATURAL RESOURCES. Agriculture, forestry, forest
fire protection, irrigation drainage, flood control, etc.,
and 14. EMPLOYMENT SECURITY STATE
PARKS AND RECREATION. Provision, maintenance GOVERNMENTS ONLY
and operation of parks, playgrounds, swimming pools,
auditoriums, museums, marinas, zoos, etc.
7. HOSPITALS AND SANATORIUMS. Operation and 15. OTHER (Specify on Page Four)
maintenance of institutions for inpatient medical care.
EEOC FORM 164 FEB 97 (Previous Editions are Obsolete) PAGE 1
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APPENDIX A 105
D. EMPLOYMENT DATA AS OF JUNE 30
(Do not include elected/appointed officials. Blanks will be counted as zero)
1. FULLTIME EMPLOYEES (Temporary employees are not included)
MALE FEMALE
AMERICAN AMERICAN
NONHISPANIC
ANNUAL
ASIAN INDIAN NONHISPANIC ASIAN INDIAN
ORIGIN OR OR
SALARY OR ORIGIN OR
TOTAL PACIFIC ALASKAN PACIFIC ALASKAN
(In thousands
000)
(COLUMNS BK) WHITE Black HISPANIC ISLANDER NATIVE White Black HISPANIC ISLANDER NATIVE
A B C D E F G H I J K
1. $0.115.9
2. 16.019.9
3. 20.024.9
4. 25.032.9
5. 33.042.9
6. 43.054.9
7. 55.069.9
8. 70.0 PLUS
9. $0.115.9
10. 16.019.9
11. 20.024.9
12. 25.032.9
13. 33.042.9
14. 43.054.9
15. 55.069.9
16. 70.0 PLUS
17. $0.115.9
18. 16.019.9
19. 20.024.9
20. 25.032.9
21. 33.042.9
22. 43.054.9
23. 55.069.9
24. 70.0 PLUS
25. $0.115.9
26. 16.019.9
27. 20.024.9
28. 25.032.9
29. 33.042.9
30. 43.054.9
31. 55.069.9
32. 70.0 PLUS
33. $0.115.9
34. 16.019.9
35. 20.024.9
36. 25.032.9
37. 33.042.9
38. 43.054.9
39. 55.069.9
40. 70.0 PLUS
41. $0.115.9
42. 16.019.9
43. 20.024.9
44. 25.032.9
45. 33.042.9
46. 43.054.9
47. 55.069.9
48. 70.0 PLUS
EEEEOC FORM 164, FEB 97 (Previous Editions are Obsolete) PAGE 2
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106 COLLECTING COMPENSATION DATA FROM EMPLOYERS
D. EMPLOYMENT DATA AS OF JUNE 30 (Cont.)
(Do not include elected/appointed officials. Blanks will be counted as zero)
1. FULLTIME EMPLOYEES (Temporary employees are not included)
MALE FEMALE
NONHISPANIC NONHISPANIC
AMERICAN AMERICAN
ORIGIN ASIAN
ORIGIN ASIAN
ANNUAL INDIAN INDIAN
SALARY TOTAL OR OR OR OR
(In thousands (COLUMNS B PACIFIC ALASKAN PACIFIC ALASKAN
000) K) WHITE Black HISPANIC ISLANDER NATIVE White Black HISPANIC ISLANDER NATIVE
A B C D E F G H I J K
49. $0.115.9
50. 16.019.9
51. 20.024.9
52. 25.032.9
53. 33.042.9
54. 43.054.9
55. 55.069.9
56. 70.0 PLUS
57. $0.115.9
58. 16.019.9
59. 20.024.9
60. 25.032.9
61. 33.042.9
62. 43.054.9
63. 55.069.9
64. 70.0 PLUS
65. TOTAL FULL TIME
(LINES 1 – 64)
2. OTHER THAN FULLTIME EMPLOYEES (Including temporary employees
66. OFFICIALS/ADMIN
67. PROFESSIONALS
68. TECHNICIANS
69. PROTECTIVE SERVICE
70. PARAPROFESSIONAL
71. ADMIN. SUPPORT
72. SKILLED CRAFT
73. SERVICE/MAINTENANCE
74. TOTAL OTHER THAN
FULL TIME
(LINES 66 – 73)
3. NEW HIRES DURING FISCAL YEAR Permanent full time only JULY 1 – JUNE 30
75. OFFICIALS/ADMIN
76. PROFESSIONALS
77. TECHNICIANS
78. PROTECTIVE SERVICE
79. PARAPROFESSIONAL
80. ADMIN. SUPPORT
81. SKILLED CRAFT
82. SERVICE/MAINTENANCE
83. TOTAL NEW HIRES
(LINES 75 – 82)
EEEEOC FORM 164, FEB 97 (Previous Editions are Obsolete) PAGE 3
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APPENDIX A 107
REMARKS (List National Crime Information Center (NCIC) number
assigned to any Criminal Justice Agencies whose data
are included in this report)
***LIST AGENCIES INCLUDED ON THIS FORM***
CERTIFICATION. I certify that the information given in this report is correct and true to the best of my knowledge and was reported in
accordance with accompanying instructions. (Willfully false statements on this report are punishable by law, US Code, Title 18, Section
1001.)
NAME OF PERSON TO CONTACT REGARDING THIS FORM TITLE
ADDRESS (Number and Street, City, State, Zip Code) TELEPHONE NUMBER
extension:
FAX NUMBER
DATE TYPED NAME/TITLE OF AUTHORIZED OFFICIAL SIGNATURE
EMAIL
EEOC FORM 164, FEB 97 (Previous Editions Obsolete) PAGE 4
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108 COLLECTING COMPENSATION DATA FROM EMPLOYERS
EQUAL EMPLOYMENT OPPORTUNITY COMMISSION FORM APPROVED BY OMB
ELEMENTARY-SECONDARY STAFF INFORMATION (EEO-5) NO. 3046-0003
APPROVAL EXPIRES
Public school systems This is a joint requirement of the EEOC and the Office for Civil
Rights, U.S. Department of Education and the U.S. Department of
Justice.
DO NOT ALTER INFORMATION PRINTED IN THIS BOX.
NOTE: ALL EMPLOYEES IN YOUR SCHOOL DISTRICT MUST BE INCLUDED ON THIS FORM. Additional Copies of this form may be obtained from the address
below. Send your full report to:
PART I. IDENTIFICATION
A. TYPE OF AGENCY WHICH OPERATES THE REPORTING SCHOOL SYSTEM
Local Public School Special Regional Agency State Education Agency
Other (Specify) ____________________________________
B. SCHOOLS SYSTEMS IDENTIFICATION (OMIT IS SAME AS LABEL)
NAME
STREET AND NO. OR POST OFFICE BOX CITY/TOWN COUNTY STATE ZIP
C. GENERAL STATISTICS
NUMBER OF SCHOOLS OPERATED NUMBER OF ANNEXES OPERATED OCTOBER 1ST ENROLLMENT
D. REMARKS
EEOC FORM 168A Page 1
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APPENDIX A 109
DO NOT INCLUDE ELECTED/APPOINTED OFFICIALS (SEE DEFINITION IN
PART II. Staff Statistics of (DATE) ________________________
APPENDIX)
DISTRICT NAME: _______________________________________
A. FULL-TIME STAFF
Race/Ethnicity
Activity
Assignment Hispanic or Non -Hispanic or Latino
Classification Latino Total
Male Female Col
A-N
Black or African
or Alaska Native
American Indian
Native Hawaiian
American Indian
or Other Pacific
Two or more
Native Hawaiian
Black or African
Two or more
or Other Pacific
American
or Alaska
Islander
Female
Native
White
White
Asian
Asian
races
Male
races
American
Islander
A B C D E F G H I J K L M N O
1. Officials,
Administrators,
Managers
2. Principals
3. Assistant Principals,
Teaching
4. Assistant Principals,
Non-teaching
5. Elementary Classroom
Teachers
6. Secondary Classroom
Teachers
7. Other Classroom
Teachers
8. Guidance
9. Psychological
10. Librarians/
Audiovisual Staff
11. Consultants &
Supervisors of
Instruction
12. Other Professional
Staff
13. Teachers Aides
14. Technicians
15. Administrative
Support Workers
16. Service Workers
17. Skilled Crafts
18. Laborers and Helpers
19. TOTALS (1-18)
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110 COLLECTING COMPENSATION DATA FROM EMPLOYERS
B. PART-TIME STAFF
Activity
Race/Ethnicity
Assignment
Classification Hispanic Non -Hispanic or Latino
or Latino
Male Female
Black or African
or Alaska Native
American Indian
Native Hawaiian
American Indian
Native Hawaiian
Black or African
or Other Pacific
or Other Pacific
Two or more
Two or more
American
or Alaska
Islander
Female
Native
White
White
Asian
Asian
races
Male
races
American
Islander
20. Professional
Instructional
21. All Other
22. TOTALS (20-21)
C. NEW HIRES FULL-TIME (JULY THRU SEPT. OF THE SURVEY YEAR)
23. Officials,
Administrators,
Managers
24. Principals/Assistant
Principals
25. Classroom Teachers
26. Other Professional
Staff
27. Nonprofessional
Staff
28. TOTALS (23-27)
CERTIFICATION: I certify that the information given in this report is correct and true to the best of my knowledge and was prepared in
accordance with accompanying instructions. Willfully false statements on this report are punishable by law, U.S. Code, Title 18, Section 1001.
Date Phone: Typed Name/Title of Person Responsible for Report Signature
Fax:
Email:
EEOC FORM 168A PREVIOUS EDITIONS ARE OBSOLETE
