FYI, Excellent opportunity at an excellent agency. Documents are attached.
For questions, you can contact the supervisor directly:
Dean M. Georgiev
Supervisor, New Visions Program
Ho`opono Services for the blind
1901 Bachelot Street
Honolulu, HI 96817
Phone: (808) 586-5289
DGeorgiev at dhs.hawaii.gov
July 1, 2014
(Revised November 3, 2014)
Continuous Recruitment Until Needs Are Met
RECRUITMENT NO. DHS 14-02
ORIENTATION AND MOBILITY THERAPIST III
Oahu Employment Only, Immediate Vacancy Downtown
$3,651.00 - $4,275.00 (SR-20, Step C to G) per month*
*Note: Hiring Rates will be based on availability of funds,
the applicant's qualifications and other relevant factors
JOB DUTIES: The primary purpose of this position is to assess the need for and provide individualized orientation and mobility services in the Rehabilitation Center and as part of a professional team, to assist individuals referred by the Counseling Section, in preparing for, securing, retaining or regaining employment or in functioning more independently in the home and community. In addition, the position will assess and provide orientation and mobility services in the community when necessary to meet the varying and changing needs of the adjustment services program. Consultation and technical assistance is also provided to other branches, individuals and organizations that work with persons who are blind, visually impaired, or deaf-blind.
MINIMUM QUALIFICATION REQUIREMENTS:
Education: Graduation from an accredited four (4) year college or university with a bachelor's degree which included coursework in human anatomy, physiology or human behavior.
Excess work experience as described under the General or Specialized Experience below or any other responsible administrative, professional or analytical work experience which provided knowledge, skills, and abilities comparable to those acquired in four (4) years of successful study while completing a college or university curriculum leading to a baccalaureate degree including the coursework indicated above, may be substituted on a year-for-year basis. To be acceptable, the experience must have been of such scope, level and quality as to assure the possession of comparable knowledge, skills and abilities.
The education or experience background must also demonstrate the ability to write clear and comprehensive reports and other documents, read and interpret complex written material; and solve complex problems logically and systemically.
Experience Requirement:
Except for the substitutions provided for in this specification, applicants must have had progressively responsible experience of the kind and quality described in the statements below, or any equivalent combination of training and experience.
General Experience: One year of work experience which involved providing professional health care/social services to individuals with disabilities and provided knowledge and understanding of the cause, origin and implications of disabling conditions and the effect of physical disability on the behavior and personality of individuals.
Specialized Experience: One year of progressively responsible professional work experience which involved the provision of orientation and mobility assessment and training services to blind and visually impaired individuals.
Substitutions Allowed:
1. Applicants who graduated with a bachelor's degree in nursing, occupational therapy, physical therapy, special education, or other related major which included coursework that provided knowledge of human anatomy, physiology and human behavior; and knowledge and understanding of the cause, origin and implications of disabling conditions and the effect of physical disability on the behavior and personality of individuals, will be deemed to have met the Education and Experience requirements for the Orientation and Mobility Therapist II level.
2. Excess Specialized Experience may be substituted for the General Experience on a month for month basis.
3. Applicants who have satisfactorily completed an Orientation and Mobility program approved, or deemed to meet criteria specified by the Association for Education and Rehabilitation of the Blind and Visually Impaired, for Certification as an Orientation and Mobility Specialist, will be deemed to have met the Education and Experience requirements for the Orientation and Mobility Therapist Ill level.
HOW TO APPLY:
1. Applications are available at the Department of Human Services (DHS) - Personnel Office or at http://humanservices.hawaiLaov/employment-opportunities/ and the State Recruiting Office.
2. Complete and retum all forms to the Department of Human Services - Personnel Office, 1390 Miller Street, Room 202, Honolulu, Hawaii 96813. Your application may be rejected if the required documentation as identified below is not submitted at the time of application. A legible photocopy of your application with current information and an original signature will be accepted.
REQUIRED FORMS/DOCUMENTATION:
You must submit the following forms/documentation together with your application or your application may be rejected:
1. Evidence of the appropriate training (e.g. transcripts or diploma) to be given credit for education. A photocopy will be accepted; however, DHS reserves the right to request for an official copy.
2. The Supplement Form for Orientation and Mobility Therapist III
NOTIFICATION TO APPLICANTS:
The Department of Human Services will use electronic mail (email) or notify applicants in writing of important information relating to the status and processing of your application as a part of our ongoing efforts to increase operational efficiency, promote the conversation of green resources, and minimize delays and costs.
Please ensure that the email address and contact information you provide is current, secure, and readily accessible to you. We will not be responsible in any way if you do not receive or check your email-box in a timely manner.
TESTING INFORMATION:
The examination for this recruitment will be conducted on an unassembled basis, where the examination score is based on an evaluation and rating of your education and experience. Therefore, it is important that your employment application provide a clear and detailed description of the duties and responsibilities of each position you held.
In-person interviews and/or further testing in Hawaii may be required at the discretion of the hiring agency. If in-person interviews and/or further testing is a requirement, applicants who meet the minimum qualification requirements and are referred to the vacancy must be available to participate in person and at their own expense in this required phase of the selection process.
Applicants are encouraged to submit their applications as soon as possible. In addition to employment availability and score, the referral of qualified applicants may be based upon other factors including date of receipt of the application.
QUALITY OF EXPERIENCE: Your possession of the required amount of experience will not in itself be accepted as proof of qualification for the position. Overall paid or unpaid experience must be of such scope and responsibility as to conclusively demonstrate that you have the ability to perform the duties of the position. Provide a detailed description of your duties and responsibilities. If you worked on a part-time basis, indicate the average number of hours you worked per week.
NOTE: The Department of Human Services will not withhold the referral of names of eligibles for employment consideration because of your failure to provide accurate and complete information conceming your qualifications.
HOW TO FILE: Applications should be submitted in person or by mail to: Department of Human Services 1390 Miller Street, Room 202 Honolulu, Hawaii 96813
WHEN TO FILE: File applications immediately. Mailed applications and supplemental materials should be postmarked by midnight of the last day to file applications. For positions indicating Continuous Recruitment Until Needs Are Met, the last day to file applications will be posted in the Personnel Office at the address listed above.
IMPORTANT INFORMATION FOR STATE OF HAWAII CIVIL SERVICE EMPLOYMENT
State of Hawaii Department of Human Services
Personnel Office ? 1390 Miller Street, Room 202 ? Honolulu, HI 96813
The information you provide will be used to determine whether you meet public employment requirements and the minimum qualification requirements in the Class Specifications. As required by Federal and/or State laws, we do not discriminate on the basis of age, sex (including gender identity or expression), religion, race, color, ancestry, national origin, disability, marital status, veteran's status, sexual orientation, arrest or court record, citizenship, genetic information or any other protected characteristics. The State of Hawaii is an equal opportunity employer and complies with applicable State and Federal laws relating to employment practices.
MERIT CIVIL SERVICE SYSTEM: The employment of persons in the civil service, as defined by State law, is governed by the merit principle. Applicants must meet the minimum qualification requirements of the position being sought, including all education, experience, licensure, certification, security clearances, and other public employment requirements for State Civil Service employment. It is the applicant's responsibility to provide complete information. The information submitted may be verified. Applicants must meet the requirements and qualify on appropriate employment related tests to be eligible for employment consideration.
LEGAL AUTHORIZATION TO WORK REQUIREMENT: The State of Hawaii requires all persons seeking employment with the government of the State shall be citizens, nationals, or permanent resident aliens of the United States, or eligible under federal law for unrestricted employment in the United States.
HAWAII STATE RESIDENCY REQUIREMENT: Effective July 1, 2007, persons who are non-residents of the State of Hawaii will have thirty (30) days from the date they begin their State employment to become Hawaii residents. While an employee of the State of Hawaii, they must maintain their Hawaii residency.
PHYSICAL/MEDICAL REQUIREMENTS: Applicants must be able to perform the essential functions of the position effectively and safely, with or without reasonable accommodation.
REASONABLE ACCOMMODATION: Applicants with special needs should contact our Civil Rights Compliance Officer during business hours at (808) 586-4955 at the time of application.
LANGUAGE ACCESS ASSISTANCE: All of our written and oral material will be provided to you in English. If you need assistance, please contact our department's Civil Rights Compliance Officer by telephone at (808) 586-4955 during normal business hours or write to the Civil Rights Compliance Officer, Department of Human Services, 1390 Miller Street, Room 202, Honolulu, HI 96813.
VETERANS PREFERENCE POINTS: (Open Competitive Recruitments Only). To receive 5 Veterans Preference Points, an applicant must submit a copy of the DD214 (Member 4) verifying dates of honorable service. To receive 10 Veterans Preference Points, submit a copy of an official statement/letter from the U.S. Department of Veteran Affairs or armed service dated within the past 12 months which confirms your qualification to receive 10 points preference.
CRIMINAL HISTORY RECORD CHECK: Individuals who are recommended for hire are required to undergo a criminal history record clearance and other checks, as applicable.
DEPARTMENT OF HUMAN SERVICE'S LEVELS OF REVIEW: Applicants will be notified of their status in writing. Applicants who do not agree with a decision or action taken by the Department of Human Services shall have two successive levels of review. Each review must be concluded before an applicant may request the next higher review. Note that each review is addressed to a specific office.
1. INTERNAL COMPLAINT. This is the first level of review. An applicant who does not agree with an action taken on your application, may file an Internal Complaint with the Department of Human Services. This must be done by submitting the Department of Human Services Internal Complaint Form, DHS9005 to the Department of Human Services, Personnel Office within (7) working days after the date of the notice. A review will not be conducted if you do not file your complaint within the seven (7) working day limit.
2. APPEAL TO THE MERIT APPEALS BOARD. An appeal to the Merit Appeals Board is the second level of review. An applicant who does not agree with an action resulting from the Internal Complaint with the Department of Human Services may then file an appeal to the Merit Appeals Board. Further information and details regarding procedures, required forms, and the mailing address to file an appeal are available at http://hawaii.gov/hrd/main/ecd/mab. If the applicant does not agree with the internal complaint decision rendered by the Department of Human Services, it may be appealed in writing to the State Merit Appeals Board within twenty (20) days from the date of the action on the internal complaint. An internal complaint must have been completed by the Department of Human Services before an appeal may be requested.
If you have questions, please contact our office during business hours at (808) 586-4969 for further information.
STATE OF HAWAII
APPLICATION FOR CIVIL SERVICE POSITIONS
DEPARTMENT OF HUMAN SERVICES
Personnel Office / RES
P.O. Box 339, Honolulu, Hawaii 96809-0339
GENERAL INSTRUCTIONS: Please type or print legibly in blue or black ink.
The information you provide will be used to determine whether you qualify for the job(s), for which you are applying.
? Your entire application and attachments (if any) must be received only at the Personnel Office above.
? Before applying, read the position requirements described in the Announcement carefully to determine if you qualify for the position.
? Any additional required forms described in the Announcement can be obtained from this office.
? Answer the questions completely and accurately. Your application may be rejected if it is incomplete or you may be disqualified or dismissed from employment if you provide false information.
? You must notify this office in writing of any changes to your name, addresses, telephone numbers or availability information.
? We will not be responsible for any mail or correspondence which does not reach you.
? Your application and supporting documents are confidential and become our property. Please keep copies for your own record.
? The information you submit on this form may be verified.
? The information on pages 1 and 2 will not be released to persons involved in the appointment process. The State of HawaPi is an equal opportunity employer and complies with applicable state and federallaws relating to employment practices.
1. CITIZENSHIP STATUS.
The State of Hawai`i requires that all persons seeking employment with the government of the State shall be citizens, nationals, or permanent resident aliens of the United States, or eligible under federal law for unrestricted employment in the United States.
q I acknowledge I have read and understood the above information.
2. UNITED STATES MILITARY SERVICE/ VETERAN'S PREFERENCE
Note: Veteran's Preference is only applicable for open-competitive recruitments.
If you are claiming Veteran's Preference, please scan and attach a copy of your DD-214 form and/or official statement from the Veterans Administration or armed forces to your application.
q None
q I am claiming 5 Veteran's Preference points and will submit a copy of my DD-214.
q I am claiming 10 Veteran's Preference points and will submit a copy of my DD-214 and/or official statement from the Veterans Administration (VA), as applicable.
If you are claiming U.S. Military Service, please complete the following:
A. Date Entered Service:
B. Date Separated From Service:
9. CERTIFICATE OF APPLICANT
I hereby certify that all statements in this application are true and correct to the best of my knowledge, and I agree and understand that any misstatements of material facts herein may cause forfeiture of all rights to any employment in the service of the State of Hawai`i. I have read the terms or conditions stated on this application and understand that there may be additional employment-related tests as required.
Date Original Signature of Applicant
STATE OF HAWAII APPLICATION FOR CIVIL SERVICE POSITIONS
The information on pages 1 and 2 will not be released to persons involved in the appointment process.
Information requested in items 10 through 19 is needed to make determinations on your suitability for employment. Dismissals from employment or dishonorable separations from military service do not automatically disqualify you from employment. The circumstances of each individual case will be evaluated against the requirements of the position for which you have applied, to determine suitability for employment.
10. DISMISSALS FROM EMPLOYMENT AND/OR DISHONORABLE SEPARATIONS FROM MILITARY SERVICE Within the past five years, were you:
A) Fired, terminated for cause, dismissed, discharged or asked to resign from employment9 ?YES ?NO
B) Separated from military service under conditions other than honorable? ?YES ?NO
(If you answer "Yes" to question 10A or 10B, please explain in detail in item #11 below, the dates and reasons for your dismissal from employment or separation from military service. For dismissals from employment, provide also the name and address of the employer.)
11.
12. WITHIN THE PAST THREE (3) YEARS, HAVE YOU BEEN CONVICTED OF ANY
OFFENSE RELATED TO CONTROLLED SUBSTANCES? ?YES I INO
(If you answer "Yes" to the above questions please explain in detail in item #13 below, the dates,
nature and circumstances of the conviction; the sentence imposed and its current status; and any other
relevant information you wish to provide.)
13.
14. HAVE YOU EVER BEEN CONVICTED OF ANY ACT, ATTEMPT OR CONSPIRACY TO
OVERTHROW THE STATE OR FEDERAL GOVERNMENT BY FORCE OR VIOLENCE? FIYES ?NO
(If you answer "Yes" to the above question, please explain in detail in item #15 below, the dates,
nature and circumstances of the conviction; the sentence imposed and its current status; and any other
relevant information you wish to provide.)
15.
16. SUSPENSION OR REVOCATION OF LICENSE
Was your license or certification to practice in a regulated profession (for example,
physician, engineer, nurse, plumber, etc.) ever suspended or revoked? FIYES ?NO
(If you answer "Yes," please explain in detail in item #17 below, the type of license; the date; the state; the specific board or organization that suspended or revoked your license; the circumstances of the suspension or revocation; and any other relevant information you wish to provide.)
17.
18. SETTLEMENTS OR AGREEMENTS
Have you accepted a settlement, a cash buyout such as through the State's Separation Incentive Program or are you subject to any restriction limiting or precluding you from seeking or securing employment
with the State of Hawaii? FlYES I INO
(If you answer "Yes," to question 18, please explain in detail in item #19 below, the reason and date of your settlement or restriction from applying with the State of Hawai`i.)
19.
STATE OF HAWAI'I DEPARTMENT OF HUMAN SERVICES
Application For Civil Service Positions
EDUCATION AND EMPLOYMENT HISTORY
1. POSITION TITLE APPLYING FOR
2. RECRUITMENT NUMBER APPLYING FOR:
The information you provide will be used to determine whether you meet the minimum qualification requirements in the Class Specifications. As required by federal and/or state laws, we do not discriminate on the basis of age, sex (including gender identity or expression), religion, race, color, ancestry, national origin, disability, marital status, veteran's status, sexual orientation, arrest and court record, citizenship, genetic information or any other protected characteristic. The State of Hawai` i is an equal opportunity employer and complies with applicable state and federal laws relating to employment practices.
3.
NAME:
Last First Middle
4. OTHER NAMES USED OR FORMER
LAST NAME.
5. E-MAIL
ADDRESS.
6. MAILING ADDRESS:
P.O. Box or Number and Street
City State Zip Code
7. PHONE NO.:
Home Other
?
8. EDUCATION HISTORY: When verification is required, the documentation must be submitted at the time of the application. If not, you may not receive credit for the training and/or your application may be considered incomplete and rejected. The information you provide in this section will be used strictly in the evaluation of
your qualifications for the position(s) for which you are applying. The information you submit on this form may be verified.
A. NAME AND LOCATION (city and state) of last grade school attended: (elementary, intermediate or high school)
(School name/type) (City/State/Country)
Did you graduate? EYes No If no, what grade level did you complete?
Did you receive a GED? []Yes No
B. TRAINING: In-service training, business, trade, armed forces, college or university, graduate of professional schools.
NAME & ADDRESS Course or Major
Field of Study Number or Hours Semester of Credits Completed Quarter Kind of Degree,
Diploma or Certificate
Received
? .
9. LICENSES, CERTIFICATES, OTHER QUALIFICATIONS
A. DRIVER'S LICENSE: Yes, I have a valid driver's license or I am able to obtain a valid driver's license by the time of appointment.
No, I do not have a driver's license and/or I am not interested in being considered for positions which require a driver's license.
B. OTHER LICENSES OR CERTIFICATES: Please indicate the kind, registration number, and the State or other licensing authority. If proof of evidence is required, please submit a photocopy or present for verification.
C. KNOWLEDGE OF LANGUAGE OTHER THAN ENGLISH: List the language and check the appropriate block(s). Some positions require the ability to speak, read, and/or write in a language other than English. D. SPECIAL QUALIFICATIONS: Include membership in professional or scientific societies, honors, awards, fellowships, publications (list but do not submit unless requested), etc.
LANGUAGE SPEAK READ WRITE
4 .
STATE OF HAWArl DEPARTMENT OF HUMAN SERVICES Application For Civil Service Positions EDUCATION AND EMPLOYMENT HISTORY
10. EXPERIENCE: Please type or print legibly in blue or black ink. Begin with your present or last employment/training and work backwards. Describe all employment/training, including military service and volunteer work. Use separate blocks if your duties and responsibilities changed while working for the same employer. To receive full credit for your experience, describe in detail the tasks you were assigned. If you supervised others, explain your duties as a supervisor and indicate the number and job duties of employees you supervised. If more space is needed provide the information on a blank sheet titled "Experience" and attach it to this form. Information you submit on this form may be verified.
Please complete this section even if you are attaching a resume or other documents.
11Your Present or Last Position 1 Employer From:
Address Month Year
To:
Month Year
[Full Time nPart Time ? Volunteer
Average hours worked per week
Supervisor's Name and Title
Company Phone Number
Company URLIntemetAddress
Starting Salary $ Per
Your Position Title and Duties
Ending Salary $ Per
Reason(s) for leaving
May we contact this employer? ? Yes ? No
.
Do you supervise? ? Yes ? No Ifyes, how many employees?
Employer From:
Address Month Year
To:
Month Year
Full Time Part Time n Volunteer
Average hours worked per week
Supervisor's
Name and Title
Company
Phone Number
Company
URLIntemetAddress
Starting Salary $ Per
Your
Position Title and Duties
Ending Salary $ Per
Reason(s) for leaving
May we contact this employer? ? Yes ? No
Did you supervise? ? Yes ? No If yes, how many employees?
Employer From:
Address
Month Year
To:
Your Supervisor's
Name and Title Month Year
qFull Time nPart Time ? Volunteer
Average hours worked per week
Company
Phone Number
Company
URL Internet Address
Starting Salary $ Per
Position Title and Duties _
Ending Salary $ Per
Reason(s) for leaving
May we contact this employer? ? Yes ? No
Did you supervise? ?Yes ? No If yes, how many employees?
Employer From:
Address Month Year
To:
Month Year
qFull Time nPart Time ? Volunteer
Average hours worked per week
Your Supervisor's
Name and Title
Company
Phone Number
Company
URL Internet Address
Starting Salary $ Per
Position Title and Duties
Ending Salary $ Per
Reason(s) for leaving
Did you supervise? ?Yes ? No Ifyes, how many employees? May we contact this employer? ? Yes ? No
01/12
NAME
RECRUITMENT NUMBER:
SUPPLEMENTAL FORM FOR
ORIENTATION AND MOBILITY THERAPIST III
Complete and submit this supplement in addition to your application. This supplement will be used along with the information provided on your application to evaluate your qualifications. INCOMPLETE INFORMATION on this supplement may result in the REJECTION of your application.
Complete a separate form for EACH position you held where you gained the relevant experience as described below. BE SURE TO COMPLETE A SEPARATE FORM FOR EACH CHANGE IN TITLE, PROMOTION, OR IF YOUR DUTIES CHANGED SIGNIFICANTLY. You may duplicate this form or attach plain sheets of paper for each additional position. Do NOT submit a resume, etc. in place of this Supplemental Form.
NOTE: In your write-up, avoid using vague and ambiguous terms such as "was responsible for," "researched," "handled," "processed," etc. Instead, use specific language which shows clearly the exact nature of the tasks you performed, and the extent of your involvement.
Section I: Education Requirement
1. Do you possess a bachelor's degree from an accredited college or university which included coursework in human anatomy, physiology or human behavior? If yes, you must submit a copy of your transcripts together with your application in order to be given credit for education.
Yes No
Name of College or University:
Dates attended: (From and To, Month and Year)
Type of Degree: Major Field of Study
Section II: General Experience Requirement
2. Do you have one year of work experience which involved providing professional health care/social services to individuals with disabilities and provided knowledge and understanding of the cause, origin and implications of disabling conditions and the effect of physical disability on the behavior and personality of individuals?
Yes No
If you answered "Yes", for each job, complete "a" through "h" below. BE SURE TO COMPLETE A SEPARATE FORM FOR EACH CHANGE IN TITLE, PROMOTION, OR IF YOUR DUTIES CHANGED SIGNIFICANTLY.
Duplicate this form or use additional sheets of paper as necessary.
Orientation and Mobility Therapist III Supplemental Form Page 2
a. Name of Employer:
b. Complete dates of employment: from: to:
month/year month/year
c. Average number of hours worked per week:
d. Title of your position:
e. Dates employed in this position: from: to:
month/year month/year
f. List the name(s) and title(s) of your immediate supervisor(s):
g. List the number and title(s) of the people you supervised:
h. Give a DETAILED description of your duties and responsibilities, and give a
breakdown of the average hours per week spent performing each of your duties and responsibilities.
Section III: Specialized Experience Requirement
3. Do you have one year of progressively responsible professional work experience which
involved the provisions of orientation and mobility assessment and training services to blind and visually impaired individuals?
Yes No
Orientation and Mobility Therapist III Supplemental Form Page 3
If you answered "Yes", for each job, complete "a" through "h" below. BE SURE TO COMPLETE A SEPARATE FORM FOR EACH CHANGE IN TITLE, PROMOTION, OR IF YOUR DUTIES CHANGED SIGNIFICANTLY. Duplicate this form or use additional sheets of paper as necessary.
a. Name of Employer:
b. Complete dates of employment: from: to:
month/year
c. Average number of hours worked per week:
d. Title of your position:
e. Dates employed in this position: from:
month/year month/year
f. List the name(s) and title(s) of your immediate supervisor(s):
g. List the number and title(s) of the people you supervised:
h. Give a DETAILED description of your duties and responsibilities in EACH of the
areas (a through f) and give a breakdown of the average hours per week spent performing each of your duties and responsibilities.
Orientation and Mobility Therapist III Supplemental Form Page 4
4. Did you satisfactorily complete an Orientation and Mobility program approved, or
deemed to meet criteria specified by the Association for Education and Rehabilitation of the Blind and Visually Impaired, for Certification as an Orientation and Mobility
Specialist that you would like us to consider? If yes, you must submit a copy of your certification together with your application in order to be given credit.
Yes No
.Date of Certification:
*******************************************************************************
I hereby certify that all statements in this form are true and correct, to the best of my knowledge. I agree and understand that any misstatements of material facts herein may cause forfeiture of all rights to any employment with the State of Hawaii Civil Service.
I further request and authorize the employer, his agent and/or the contact person named herein to furnish verification of the statements made herein and/or employment information requested by the Department of Human Services of the State of Hawaii.
Date Signature
STATE OF HAWAI'I
Department of Human Resources Development ? State Recruiting Office
235 South Beretania Street, Room 1100, Honolulu, Hawai'i 96813-2437
APPLICANT DATA SURVEY
(Page 1 of 2)
NAME DATE
Please complete one Applicant Data Survey form for each job you apply for. If applying for more than one level of work appearing in the same State of Hawai'i Career Opportunity announcement, complete an additional line for each additional level of work.
JOB(S)
APPLYING
FOR -rp T E --s4 '-'' ,, '-,:-.,. -4,-, - gasdjTtmTtNp'?*?BIBE
APPLICANT DATA SURVEY (Optional)
The State of Hawai'i invites employees and applicants to voluntarily self-identify their age, sex, race or ethnicity, and language skills. Submission of this information is VOLUNTARY and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept CONFIDENTIAL and may only be used in accordance with provisions of applicable laws, executive orders, and regulations.
AGE ? Under 20 ? 20 - 24 ? 25 - 29 ? 30- 39 ? 40 - 49 ? 50 and over
GENDER 0 Male
0 Female
ETHNICITY (Check the box below if you are of Hispanic Origin)
? Hispanic or Latino: All persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or
origin, regardless of race.
RACE (Select one or more racial categories below to describe yourself)
? White: All persons having origins in any of the original peoples of Europe, the Middle East, or North Africa.
(e.g., persons who identify as Portuguese, German, Lebanese, Arab, or Egyptian).
? Black or African American: All persons having origins in any of the Black racial groups of Africa. ,
? American Indian or Alaskan Native: All persons having origins in any of the original peoples of North and South
America (including Central America), and who maintain cultural identification through tribal affiliation or community recognition.
Native Hawaiian and Pacific Islander: All persons having origins in any of the original peoples of Hawai'i, Guam, Samoa, or
other Pacific Islands - Native Hawaiian, Guamanian or Chamorro, Samoan, etc.
0 Native Hawaiian ? Part Native Hawaiian ? Tongan 0 Samoan 0 Guamanian or Chamorro
? Other Pacific Islander
For Example: Belauan, Chuukese, Cook Islands, Fijian, Kosraean, Maori, Marshallese, Papua New Guinea, Pohnpeian, Rapa Nui, Solomon Islands, Tahitian, Vanuatu, Yapese, etc.
Asian: All persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
Sub-continent: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
0 Chinese ? Japanese ? Korean ? Filipino ? Vietnamese
? Other Asian
For Example: Bangladesh, Bhutan, Cambodia, India, Indonesia, Laos, Malaysia, Mongolia, Myanmar, Nepal, Pakistan, Singapore, Sri Lanka, Taiwan, Thailand, Yemen, etc.
Note: Race/ethnic designations as used by the U.S. Equal Employment Opportunity Commission (EEOC) do not denote scientific definitions of anthropological origins.
STATE OF HAWAII
Department of Human Resources Development ?State Recruiting Office
235 South Beretania Street, Room 1100, Honolulu, Hawai'i 96813-2437
APPLICANT DATA SURVEY
(Page 2 of 2)
FOREIGN (NON-ENGLISH) SPOKEN (OR SIGN) LANGUAGE SKILLS (Select from the languages/dialects listed below)
? Not Applicable ? Afrikaans ? Amharic ? Arabic ? American Sign Language
? Bahasa (Indonesian) ? Bengali ? Burmese ? Cantonese (Chinese)
? Chamorro ? Chuukese ? Mandarin (Chinese) n Croatian
? Shanghai (Chinese) ? Taiwanese (Chinese) ? Teochew/Chaozhou (Chinese)
? Czech ? Danish ? Dutch ? Farsi (Persian) ? Flemish
? French ? Finish ? German ? Greek ? Hawaiian
? Haitian Creole ? Hebrew ? Hungarian ? Kannada (India) ? Konkani (India)
? Hindi (India) ? Punjabi(India) ? Italian ? Japanese ? Khmer (Cambodian)
? Kiswahili ? Korean ? Kosraean ? Latvian ? Lithuanian
? Laotian ? Latin ? Malay ? Marshallese ? Mongolian
? Myanmar ? Norwegian ? Okinawan ? Cebuano Visayan (Philippines)
? Ilokano (Philippines) ? Ilonggo Visayan (Philippines) ? Polish ? Portuguese
? Pohnpeian ? Rumanian ? Russian ? Samoan ? Swahili
? Spanish ? Serbo-Croatian ? Swedish ? Tagalog (Philippines)
? Telugu ? Thai ? Tamil (India) ? Tamil (Ceylon) ? Tongan
? Turkish ? Twi (Ghana) ? Ukrainian ? Urdu (Pakistan) ? Vietnamese
? Welsh ? Wolof ? Yapese ? Other - Pls. specify:
Please select one (1) of the following on your fluency in the language/dialect as referenced above. n Native or ? Conversational ? Simple phrases ? Not applicable
Native-like
Rate your ability to SPEAK the language / dialect as referenced above. n High ? Moderate ? Low ? Not applicable
Rate your ability to READ the language / dialect as referenced above. n High ? Moderate ? Low ? Not applicable
Rate your ability to WRITE the language / dialect as referenced above. n High ? Moderate ? Low ? Not applicable
If needed, are you comfortable in assisting or interpreting for limited English clients/customers who speak your language? ? Yes ? No ? Not applicable
An Equal Opportunity Employer
ADDRESS: ISLAND:
PHONE: BUSINESS: (
Geographical Availability Please check (I) all the locations for which you are willing
Note: You must be available to work in any or all areas within the geographic area(s) that
q OAHU
q Ewa (Includes Makakilo, Kapolei, Barber's Point, Ewa Beach)
q Walpahu to Alea (Includes Waikele, Waipio, Pearl City)
q Halawa to Kallhl
(Includes Allamanu, Airport, Salt Lake, Moanalua, Mapunapuna, Kapalama, Palama, Sand Island, 'wile?
q Downtown (Includes Nuuanu, Pauoa, Maklki-Kapiolani, Ala Moana)
q Manoa to Kahala (Includes McCully, Moiliili, Waikiki, Kapahulu, Kaimuki,
Waialae, Pablo)
Alna Haina to Hawaii Kai
Walmanalo / Kallua
Kaneohe to Kualoa (Includes Kahaluu, Waiahole, Waiakane)
Kaaawa to Kahuku (Includes Punaluu, Hauula, Laie, Kuilima)
North Shore (Includes Waimea, Haleiwa, Waialua)
Wahiawa / Kunla / Milliani
Waianae Coast (Includes Nanakuli, Maili, Waianae, Makaha)
HAWAII
Hilo (includes Papaikou, Pepeekeo, Honomu, Hakalau, Ninole, Papaaloa, Laupahoehoe)
q Honokaa / Hamakua (Includes Ookala, Paauilo, Paauhau, Haina, Kukuihaele)
q Kamuela 1 Kohala / Walkoloa (Includes Halaula, Kapaau, Hawi, Kawaihae)
q Kona (Includes Keahole, Kailua-Kona, Holualoa, Keauhou, Kealakekua, Captain Cook, Honaunau)
q Ka'u (Includes Ocean View, Naalehu, Pahala)
q Puna (Includes Hawaii Volcanoes National Park, Volcano, Mountain View, Kurtistown, Keaau, Pahoa, Kapoho)
Employment Avallabilitv: Please check (?) the following conditions of employment for which you are interested and available. If you are appointed to a temporary position and have
also indicated Interest In permanent employment, we will continue to refer you to permanent positions provided you are active on the register and within referral range for the position.
Blank responses will be taken to mean that you are not available.
1. Permanent jobs ?Full-time ?Part-time
2. Temporary jobs of 2 to 5 months ?Full-time ?Park-time
3. Temporary jobs of 6 to 12 months ?Full-time ?Part-time
4. Temporary jobs of more than 12 months ?.Full-time ?Part-time 5. A job at a lower rate of pay ?Yes ?No
6. I am available for Immediate employment referral (or after 2-3 weeks notice). ?Yes ?No *Note: If you check No*, you must notify us in writing when you are available for employment referral no sooner than four weeks before you become available.
DHS 136 (rev 8/07)
Edward C. Bell, Ph.D., CRC, NOMC
Director, Professional Development and Research
Institute on Blindness
Louisiana Tech University
210 Woodard Hall
PO Box 3158
Ruston LA 71272
Office: 318.257.4554 Fax: 318.257.2259 (Fax) Skype: edwardbell2010
ebell at latech.edu http://www.pdrib.com www.pdrib.com
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"I am somehow less interested in the weight and convolutions of Einstein's brain than in the near certainty that people of equal talent have lived and died in cotton fields and sweatshops."
-- Stephen Jay Gould
