The City University of New York Non-Teaching Instructional Staff Action Form: HEO, CLT, RA LEHMAN COLLEGE OFSR Use Only Date Received UPO Action Committee Review VC Review A. Action being requested: (indicate all that apply) (See page one for definitions, required documents and other helpful information) B. Current Nature of Position: (indicate one only) New Filled on a Substitute basis Vacant, previously filled Reorganized functions Accretion of functions C. Appointment Information: D. College Approval: E. College Certification: Committee Meeting Date / / Proposed Payroll Title Proposed Functional Title Waiver Requested (Y/N) Requested Effective Date Bylaw (Type) Search Candidate’s Name Supervisor’s Name/Title To Whom Will Report Candidate’s Prior CUNY Payroll Title, if Any / / Vice President/Dean College HR Officer/Committee Liaison Date Chair, Director Text Box: Reclassification Merit Increase (one/two-step, in-title) Merit Increase (exceeding two-steps Research Assc.) Text Box: Position Approval ONLY Appointment from a Search Reorganization Plan: Related Appointment or Reclassification Promotion (CLT Series only) Substitute Appointment (to a position requiring a search)* Substitute Appointment (to a position of a temporary nature)* Functional Title Change (including Reassignment) Other: (Specify) Text Box: *Complete CUNY Substitute Appt. History Text Box: Payroll Title Text Box: Sub. Appt Period Text Box: 1. 2. 3. 4. Instructional Staff Data Form: The information below is to be completed by the college based on information supplied by the candidate. If more space is required, attach another page. The candidate should attest to the college regarding the accuracy of the information on which the college bases the information provided below. Name Address SSN Educational Background (most recent degree first): Accredited Institution City/State Dates Attended From (M/Y) To Degree Conferred/Expected Degree Field Date Recent 10 years (most recent first) paid (and unpaid, if relevant) work experience (other than with CUNY): Non-CUNY Employer Job Title/Primary Responsibility Dates Employed from (M/Y): To (M/Y) If PT, hours per week If supervisor, # supervised BLANK Recent 10 years (most recent first) work experience with CUNY: CUNY College Job Title/Primary Responsibility Dates Employed From (M/Y): To (M/Y) If PT, hours per week If supervisor, # supervised Notice to Appointment Officials: any offer of employment by an official of a college is contingent on successful completion of the total employment process, including the verification of references which the College official considers satisfactory. No manager or representative of CUNY has the authority to make an offer of employment or to represent a condition of employment which is in violation of the Bylaws, University or College policies, or collective bargaining agreements governing the administration of the Non-Teaching Instructional Staff Service of the University. Any representations which are contrary to administrative policies of the University, including those made in writing are unenforceable. Only the representations made by the President of the College or designee—usually the College HR Officer—made in writing prior to appointment constitute official representations. The City University reserves the right to revise without notice any personnel policy or practice at any time other than those set forth in the University Bylaws, applicable New York State Laws, and collectively bargained agreements. THE CITY UNIVERSITY OF NEW YORK AFFIRMATIVE ACTION CERTIFICATION For NON-TEACHING INSTRUCTIONAL STAFF (HEO, CLT, RA) The Affirmative Action Program of the City University of New York mandates that equal opportunity be afforded to all qualified persons when positions are available. Good faith efforts must be made to encourage women, minorities, veterans and persons with disabilities to apply for available vacant positions. SECTION A: RECRUITMENT PLAN CERTIFICATION A recruitment plan is to be submitted to the Office of Compliance and Diversity for approval before the search begins. I certify that I reviewed and approved the recruitment plan submitted by of Chair/Director or Responsible College Officer Department/Office For the position of Bylaw/Functional Title of Position JOB ID # Compliance and Diversity Officer Date THE APPLICANT POOL (This section will be completed by the Office of Compliance and Diversity) Black Hispanic Asian/ Pacific Islander American Indian/ Alaskan Native Italian American White Unknown Total Men Women Total SECTION B: SEARCH PROCEDURES DOCUMENTATION (This section to be completed by department) 1. Federal and University regulations require documentation of recruitment efforts. List all sources (Websites, journal and newspaper ads, professional organizations, etc.) that were used to recruit for this position: 2. Number of applications received: Male Female Total Applications 3. Provide gender and race/ethnicity data for the applicants interviewed: Black Hispanic Asian/ Pacific Islander American Indian/ Alaskan Native Italian American White Total Men Women Total 4. Name of Candidate Selected: From what specific sources was the candidate recruited: 5. If the position was offered to another candidate but that candidate declined, please complete this section: Name of candidate: Reason candidate declined the position: 6. List the names of other candidates interviewed but not offered the position: SECTION C: Affirmative Action Certification .. Before an offer is made, appropriate College officers shall certify that affirmative action procedures have been followed. In the case of reclassification, College officers must attest that the proposal conforms with all equal opportunity policies. .. Substitute positions may be for a maximum of four (4) semesters only. A PVN to begin the search for a regular line must accompany the request for the first substitute appointment. The exceptions to this are: I certify that the Affirmative Action procedures have been followed and that the above is true to the best of my knowledge and belief. Name and Signature of Responsible College Officer Department/Office Date (Chairperson/Director/Dean) Name and Signature of Director of Compliance and Diversity Date REGULATIONS REQUIRE THE RETENTION OF ALL SUPPORTING DOCUMENTS, INCLUDING RESUMES OF APPLICANTS, FOR AT LEAST THREE (3) YEARS.