Revised EEO-5 Form 168A

EQUAL EMPLOYMENT OPPORTUNITY COMMISSION ELEMENTARY-SECONDARY STAFF INFORMATION (EEO-5) Public school systems			FORM APPROVED BY OMB NO. 3046-0003 APPROVAL EXPIRES
			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
REMARKS
EEOC FORM 168A Page 1

PART II. Staff Statistics of (DATE) ________________________

DO NOT INCLUDE ELECTED/APPOINTED OFFICIALS (SEE DEFINITION IN APPENDIX)

DISTRICT NAME: _______________________________________

Activity Assignment Classification

A. FULL-TIME STAFF

Race/Ethnicity

Hispanic or Latino

Non -Hispanic or Latino

Total Col A - N

Male

Female

Male

Female

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Two or more races

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Two or more races

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)

Activity Assignment Classification

B. PART-TIME STAFF

Race/Ethnicity

Hispanic or Latino

Non -Hispanic or Latino

Male Female

Male

Female

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Two or more races

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Two or more races

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: Fax: Email:

Typed Name/Title of Person Responsible for Report

Signature

EEOC FORM 168A

PREVIOUS EDITIONS ARE OBSOLETE