CAREER OPPORTUNITY
State of Hawaii, Department of Human Services
1390 Miller Street Honolulu, Hawaii 96813

Opening Date:	06368-70:113010:13
August 30, 2016

Continuous Recruitment Until Needs Are Met
RECRUITMENT NO. DHS16-05 REHABILITATION TEACHER FOR THE BLIND II
DOWNTOWN, OAHU EMPLOYMENT ONLY $3,497.00 (SR-18) per month

JOB DUTIES:
This position assesses the need for and provide individual and group instruction in computer technology skills as part of a professional team in a day rehabilitation center setting, to assist and support the Counseling Section in preparing individuals who are blind, visually impaired, or deaf-blind for employment or independent living.
MINIMUM QUALIFICATION REQUIREMENTS:

Basic Education Requirement:
Graduation from an accredited four (4) year college or university with a bachelor’s degree.
Excess work experience as described under Genera! 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 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 Requirements:
General Experience: One year of progressively responsible professional work experience providing direct services to individuals with disabilities which provided knowledge and understanding of the implications of disabling conditions and the effect of disability on the behavior and personality of individuals.
Substitutions Allowed:
1.	A bachelor’s degree from an accredited college or university in Special Education may be substituted for all of the General Experience.
2.	A master’s degree from an accredited college or university in teaching the blind may be substituted for all of the General Experience and one (1) year of the Specialized Experience.
3.	Excess Specialized Experience (as described below) may be substituted for the General Experience on a month-for-month basis.
Specialized Experience: Progressively responsible professional work experience providing rehabilitation instruction to blind or visually impaired individuals in one or more subject areas or topics such as communication, personal management, home management, activities of daily living, recreation or leisure activities, etc.
HOW TO APPLY:
1.	Applications are available at the Department of Human Services (DHS) - Personnel Office or at htto://humansetvices.hawaii.aov/emolovment-ooDOrtunities/.
2.	Complete and return all forms to the Department of Human Services - Personnel Office, 1390 Miller Street, Room 202, Honolulu, Hawaii 96813. Your application may be rejected H 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 Supplemental Form for the Rehabilitation Teacher for the Blind II.

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 conservation 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. It is therefore 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 concerning 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

Or mail to:
Department of Human Services P.O. Box 339
Honolulu, Hawaii 96809-0339

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.

An Equal Opportunity Employer

IMPORTANT INFORMATION FOR STATE OF HAWAII CIVIL SERVICE EMPLOYMENT
State of Hawaii Department of Human Services Personnel Office -1390 Miller Street, Room 202 - Honolulu, I'll 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 nonresidents 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, I'll 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.

October 1,2014

STATE OF HAWAI‘1 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.
0 Your entire application and attachments (if any) must be received only at the Personnel Office above.
0 Before applying, read the position requirements described in the Announcement carefully to determine if you qualify for the position. 0 Any additional required forms described in the Announcement can be obtained from this office.
0 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.
0 You must notify this office in writing of any changes to your name, addresses, telephone numbers or availability information.
0 We will not be responsible for any mail or correspondence which does not reach you.
0 Your application and supporting documents are confidential and become our property. Please keep copies for your own record.
0 The information you submit on this form may be verified.
0 The information on pages 1 and 2 will not be released to persons involved in the appointment process.
The State ofHanoi*t is an equal opportunity employer and complies with applicable state and federal laws relating to employmentpractices.

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.
? 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.
I~~l None
| | I am claiming 5 Veteran’s Preference points and will submit a copy of my DD-214.
PI 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:	

POSITION TITLE APPLYING FOR

RECRUITMENT NUMBER
5.	NAME:		 _	  _
Last	First	Middle
6.	OTHER
NAMES USED OR FORMER
LAST NAME:	
7.	MAILING
ADDRESS:	
P.O. Box or Number and Street

City	State	Zip	Code
8. PHONE
NUMBER:	
Home	Other

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 HAWAI'I 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 employment?	J I YES	I iNO
B)	Separated from military service under conditions other than honorable?	EYES	| [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? 	DYES	QNO
(If you answer “Yes” to the above question, 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? 	DYES H]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?	0YES.....	(UNO
(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 Hawai‘i? 	[ |YES i |NQ
(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 7 Department of Human Resources Development

Form HRD 315(Rev.l0/2013)

STATE OF HAWAI‘1 DEPARTMENT OF HUMAN SERVICES Application For Civil Service Positions EDUCATION AND EMPLOYMENT HISTORY

8. EDUCATION HISTORY: When verification is required, the documentation must be submitted at the time of die 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? |	jYes j	]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	Come or Major Field of Study	Number t
or Horn Semester	if Credits 'omplctcd Quarter	KindofDcjpee, Diploma or Certificate
Received }	

					
					
				L		

DO NOT WRITE IN THIS SPACE

9. LICENSES, CERTIFICATES, OTHER QUALIFICATIONS
A.	DRIVER’S LICENSE: Q 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 die language and check the appropriate bJock(s). Some positions require the ability to speak, read, and/or write in a language other than English.

LANGUAGE	SPEAK	READ	WRITE	

				
D. SPECIAL QUALIFICATIONS: Include membership in professional or scientific societies, honors, awards, fellowships, publications (list but do not submit unless requested), etc.

STATE OF HAWAI‘1 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.

|vour |vour PrPresent or Last Po	Employer	From:	
	Address	“ Month Year
To:	
			
		^ Month Year
| |Full Time | [Part Time | | Volunteer Average hours woiked per week	
	Supervisor’s Name and Title Company Phone Number		
	Company URL Internet Address		
	Your Position Title and Duties	Starting Salary $ Per	
		Ending Salary $ Per Reason(s) for leaving	

			
		May we contact this employer? 0 Yes CD No	
	Do you supervise? | I Yes | |No If yes, how many employees?		
E
A	mployer	From:	
	ddress	Month Year
To:	
			
	Month Year
| [Full Time | [Part Time j | Volunteer Average hours worked per week	
St
C
c
Y	.ipervisor’s Name and Title		
	ompany Phone Number		
	ompany URL Internet Address		
	our Position Title and Duties	Starting Salary $ Per	
		Ending Salary $ Per Reason(s) for leaving	

		
		
Did you supervise? | [Yes | | No If yes, how many employees?	May we contact this employer? j	[Yes 1	|No	
Ei
A	nployer	From:	
	ddress	Month Year ”
To:	
			
	Month Year
j [Full Time | jPart Time [ | Volunteer Average hours worked per week	
Si
C«
Q
Y<	ipervisor’s Name and Title		
	Dmpany Phone Number		
	urnpany URL Internet Address		
	jut Position Title and Duties	Starting Salary $ Per	
					—					Ending Salary $ Per	
	Reason(s) for leaving	

Did you supervise? | |Yes | [No If yes, how many employees?	May we contact this employer? |	| Yes 1 iNo	
Er
A<	nployer	From:	
	idress	Month Year
Ter	
		Month Year
| [Full Time | [Part Time | 1 Volunteer
Average hours worked per week Starting Salary $ Per Ending Salary $ Per Reason(s) for leaving	
Sr
a
Cc
Yc	ipervisor’s Name and Title		
	impany Phone Number		
	tmpany URL Internet Address		
	>ur Position Title and Duties		

		
Did you supervise? | I Yes | ]No If yes, how many employees?	May we contact this employer? Q Yes 1 INo	

NAME

SUPPLEMENTAL FORM FOR REHABILITATION TEACHER FOR THE BLIND II
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 university?
Yes	No

Name of University: 	
Dates attended:	
(From and To, Month and Year)
Type of Degree:	 Major	Field	of	Study	

Note: YOU MUST SUBMIT A COPY OF YOUR TRANSCRIPTS TOGETHER WITH YOUR APPLICATION IN ORDER TO BE GIVEN CREDIT FOR

EDUCATION.

2. Do you have one year of progressively responsible professional work providing direct
services to individuals with disabilities which provided knowledge and understanding of the implications of disabling conditions and the effect of disability on the behavior and personality of individuals?
Yes	No

If you answered "Yes" to number 2 above, 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.

2a. 	Name of Employer: 		
2b. 	Complete dates of employment: from: to: 		
	month/year 	month/year 	
2c. 	Average number of hours worked per week: 		
2d. 	Title of your position: 		
2e. 	Dates employed in this position: from: to: 		
	month/year 	month/year 	
2f. 	List the name(s) and title(s) of your immediate supervisor(s): 		
2g. List the number and title(s) of the people you supervised:

2h. 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.

Specialized Experience may be substituted for the General Experience on a month-for-month basis.
3. Do you have progressively responsible work experience providing rehabilitation
instruction to blind or visually impaired individuals in one or more subject areas or topics such as communication, personal management, home management, activities of daily living, recreation or leisure activities, etc.
Yes 	No 	
If you answered "Yes" to number 3 above, 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.

3a. 	Name of Employer: 		
3b. 	Complete dates of employment: from: to: 		
	month/year 	month/year 	
3c. 	Average number of hours worked per week: 		
3d. 	Title of your position: 		
3e. 	Dates employed in this position: from: to: 		
	month/year 	month/year 	
3f. 	List the name(s) and title(s) of your immediate supervisor(s): 		
3g. 	List the number and title(s) of the people you supervised: 		

3h. Give a DETAILED description of your duties and responsibilities in EACH of the areas (a through f) described under number 3, and give a breakdown of the average hours per week spent performing each of your duties and responsibilities. Duplicate this form or use additional sheets of paper as necessary.

9|c^c}|c4(^c3{e^c9|c)|e3|c3|c3|e3|e9|c^c4e^«9}(^c3)c^c^c})(^^(^(^(3)c^c3|c3{c9{e3|e3|e^(3|c3|e3|c}|c3|e3|e3)c3|c^c9f:^e^(3)c4e^^cs|(3|c^c^c3|c3|c^e9{c9{e^c^c^c4c^(^c
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 HAWAIT 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	TITLE K	CL" . . REmuiTlfETO NUMBER	

			
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 ? Male
	?	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.
?	Native Hawaiian ? Part Native Hawaiian ? Tongan ? Samoan ? 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.
?	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.

HRD 330-ADSF | rev. 10/2014)

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 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)	? Croatian	
? Shanghai (Chinese)	? Taiwanese (Ch	nese)	? 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(lndia)	? Italian	? Japanese	? Khmer (Cambodian)	
? Kiswahili	? Korean	? Kosraean	? Latvian	? Lithuanian	
? Laotian	? Latin	? Malay	? Marshallese	? Mongolian	
? Myanmar	? Norwegian	? Okinawan	? Cebuano Visayan (Philippines)	
? llokano (Philippines)	? llonggo 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 - Pis. specify:	

Please select one (1) of the following on your fluency in the language/dialect as referenced above.	? Native or Native-like	? Conversational	? Simple phrases	? Not applicable	
	
Rate your ability to SPEAK the language / dialect as referenced above.	? High	? Moderate	? Low	? Not applicable	
	
Rate your ability to READ the language / dialect as referenced above.	? High	? Moderate	? Low	? Not applicable	
	
Rate your ability to WRITE the language / •dialect as referenced above.	? 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

HRD 330-ADSF | rev. 10/2014)

TYPE OR PRINT LEGIBLY IN INK

State of Hawaii Department of Human Services
Employment Availability Information Form

TITLE OF JOB APPLYING FOR:
NAME:
ADDRESS:	CITY:
ISLAND:	ZIP CODE:
PHONE: BUSINESS:	(	)	HOME:	(	)

DO NOT WRITE IN THIS BOX
Grade: 		
Exam No.: 		
List Est.: 		
Ext.: 		
DYes DNo

Geographical Availability	Please check (/) all the locations for which you are willing to accept employment.
Note: You must be available to work in any or all areas within the geographic area(s) that you have selected.

¦ OAHU
?	Ewa (Includes Makakilo, Kapolei, Barber's Point, Ewa Beach)
?	Waipahu to Aiea (Includes Waikele, Waipio, Pearl City)
?	Halawa to Kalihi
(Includes Aliamanu, Airport, Salt Lake, Moanalua, Mapunapuna, Kapalama, Palama, Sand Island, Iwilei)
?	Downtown (Includes Nuuanu, Pauoa, Makiki-Kapiolani, Ala Moana)
?	Manoa to Kahala (Includes McCully, Moiliili, Waikiki, Kapahulu, Kaimuki, Waialae, Palolo)
?	Aina Haina to Hawaii Kai
?	Waimanalo / Kailua
?	Kaneohe to Kualoa (Includes Kahaluu, Waiahole, Waiakane)
?	Kaaawa to Kahuku (Includes Punaluu, Hauula, Laie, Kuilima)
?	North Shore (Includes Waimea, Haleiwa, Waialua)
Q Wahiawa I Kunia / Mililani
?	Waianae Coast (Includes Nanakuli, Maili, Waianae, Makaha)

¦ MAUI
?	Wailuku / Kahului (Includes Puunene,
Paukukalo, Waiehu, Waihee)
?	Lahaina
?	Maalaea / Kihei / Wailea
?	Hana
?	Makawao (Includes Pukalani, Haliimaile, Haiku, Paia)
?	Kula
?	KAUAI
?	Lihue (Includes Hanamaulu)
?	Kapaa (Includes Wailua, Kealia, Anahola)
?	Hanalei (Includes Kilauea, Princeville, Haena)
?	Waimea (Includes Kokee, Kekaha, Kaumakani, Hanapepe, Eleele, Port Allen, Kalaheo)
?	Koloa (Includes Lawai, Omao)

Remarks:

¦ HAWAII
?	Hilo (Includes Papaikou, Pepeekeo, Honomu, Hakalau, Ninole, Papaaloa, Laupahoehoe)
?	Honokaa / Hamakua (Includes Ookala, Paauilo, Paauhau, Haina, Kukuihaele)
?	Kamuela / Kohala I Waikoloa (Includes Halaula, Kapaau, Hawi, Kawaihae)
?	Kona (Includes Keahole, Kailua-Kona, Holualoa, Keauhou, Kealakekua, Captain Cook, Honaunau)
?	Ka’u (Includes Ocean View, Naalehu, Pahala)
?	Puna (Includes Hawaii Volcanoes National Park, Volcano, Mountain View, Kurtistown, Keaau, Pahoa, Kapoho)

a LANAI
?	Lanai City
H MOLOKAI
?	Kaunakakai (Includes Maunaloa, Hoolehua, Kualapuu)
?	Kalaupapa

Employment Availability: Please check (<0 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 adive on the register and within referral range for the position. Blank responses will be taken to mean that you are not available.
?Part-time	5.	A job at a lower rate of pay	Eyes	ONo
?Part-time	6.	I am available for immediate employment referral (or after 2-3 weeks notice). Eyes	QNo
?Part-time	"Note:	If	you	check	No*,	you	must	notify	us	in	writing	when	you	are	available for employment
?Part-time	referral	no	sooner	than	four	weeks	before	you	become	available.
DHS PS (rev 8/07)
Permanent jobs	QFull-time
Temporary jobs of 2 to 5 months	?Full-time
Temporary jobs of 6 to 12 months ?Full-time Temporary jobs of more than 12 months ?Full-time