Form Eeo-4 - State And Local Government Information printable pdf download

EQUAL EMPLOYMENT OPPORTUNITY COMMISSION

APPROVED BY

OMB

STATE AND LOCAL GOVERNMENT INFORMATION (EEO-4)

3046-0008

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 8127

Reston VA 20195

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. Address--Number and Street

CITY/TOWN

COUNTY

STATE/ZIP

EEOC USE

ONLY

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

Form Eeo-4 - State And Local Government Information

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