University System of Georgia
AFFIRMATIVE ACTION CHECKLIST
Full-Time Administrative & Academic Appointments
 
  __________________________________________________
Institution
1. Position applied for: _____________________________________________________

2. Recommended applicant: _________________________________________________

(Last) (First) (Middle) 
 3. Race/Sex: _____________ /______________  4. Date of application: _______________

5. Date position offered: ____________________ 6. Date accepted: ___________________

7. Total number of applicants: ____________________

American White &
Black Hispanic Asian   Indian  Other Total
Female: _____ _____ _____ _____ _____ _____
Male: _____ _____ _____ _____ _____ _____
 
8. Number of applicants considered for final review:
American White &
Black Hispanic Asian  Indian Other Total
Female: _____ _____ _____ _____ _____ _____
Male: _____ _____ _____ _____ _____ _____
 
9. Number of applicants invited to visit campus:
American White &
Black Hispanic Asian  Indian Other Total
Female: _____ _____ _____ _____ _____ _____
Male: _____ _____ _____ _____ _____ _____
    10. Number of applicants declining offered position:
Date of Offer
Date of Refusal
Sex
Race 
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
 
11. Include a statement describing special efforts to attract minority applicants for this position. (Use back or attach separate sheet.)
Signed: ____________________________________
 Title: ______________________________________
Date:______________________________________
 Revised 5/1/84