Appendix MWBE-3.pdf

NYS Department of Labor Purchase and Contracts, MWBE Administrator

State Office Campus, Bldg 12, Room 465 Albany, New York 12240

E-mail: Labor.sm.MWBEAdmin@labor.ny.gov Phone: (518) 474-2678 Fax: (518) 457-0620

MWBE Work Force Employment Utilization/Compliance Report Submit the completed form to the address above.

Contract No: Reporting Entity:

Contractor Subcontractor Reporting Period:

January 1, 20 - March 31, 20 April 1, 20 - June 30, 20 July 1, 20 - September 30, 20 October 1, 20 - December 31, 20

Report Includes:

Work force to be utilized on this contract Contractor/Subcontractor’s total work force

Contractor’s Name:

Contractor’s Address:

FEIN: Phone No.:

Enter the total number of employees in each classification in each of the EEO-Job Categories identified.

EEO-Job Category Total Work force

Work force by Gender

Work force by Race/Ethnic Identification

Work force by Other

Male (M)

Female (F)

White

(M) (F)

Black

(M) (F)

Hispanic

(M) (F)

Asian

(M) (F)

Native American

(M) (F)

Disabled

(M) (F)

Veteran

(M) (F)

Officials/Administrators

Professionals

Technicians

Sales Workers

Office/Clerical

Craft Workers

Laborers

Service Workers

Temporary/Apprentices

Totals

Phone No.: Date:

Prepared By (signature): E-Mail Address:

Name and Title of Preparer (Print):

EEO 101 (01/15) Page 1 of 2

Appendix MWBE-3

General Instructions

The work force utilization (EEO 101) is to be submitted on a quarterly basis during the life of the contract to report the actual work force utilized in the performance of the contract broken down by the specified categories. When the work force utilized in the performance of the contract can be separated out from the contractor’s and/or subcontractor’s total work force, the contractor and/or subcontractor shall submit a Utilization Report of the work force utilized on the contract.

When the work force to be utilized on the contract cannot be separated out from the contractor’s and/or subcontractor’s total work force, information on the total work force shall be included in the Utilization Report. Utilization reports are to be completed for the quarters ending 3/31, 6/30, 9/30 and 12/31 and submitted to Purchase and Contracts within 10 days of the end of each quarter. If there are no changes to the work force utilized on the contract during the reporting period, the contractor can submit a copy of the previously submitted report indicating no change with the date and reporting period updated.

Instructions for completing:

1. Enter the number of the contract that this report applies to along with the name and address of the Contractor preparing the report.

2. Check off the appropriate box to indicate if the entity completing the report is the contractor or a subcontractor.

3. Check off the box that corresponds to the reporting period for this report. Please indicate current year.

4. Check off the appropriate box to indicate if the work force being reported is just for the contract or the Contractor’s total work force.

5. Enter the total work force by EEO job category.

6. Break down the total work force by gender and enter under the heading ‘Work force by gender.’

7. Break down the total work force by race/ethnic background and enter under the heading ‘Work force by Race/Ethnic Identification.

8. Enter information on any disabled or veteran employees included in the work force under the appropriate heading.

9. Enter the name, title, phone number and email address for the person completing the form. Sign and date the form in the designated boxes.

Race/Ethnic Identification Race/ethnic designations as used by the Equal Employment Opportunity Commission do not denote scientific definitions of anthropological origins. For the purposes of this report, an employee may be included in the group to which he or she appears to belong, identifies with, or is regarded in the community as belonging. However, no person should be counted in more than one race/ethnic group. The race/ethnic categories for this survey are:

White: (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Black: A person, not of Hispanic origin, who has origins in any of the black racial groups of the original peoples of Africa.

Hispanic: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

Asian & Pacific Islander: A person having origins in any of the Far East countries, Southeast Asia, the Indian subcontinent or the Pacific Islands.

Native Indian (Native American/Alaskan Native): A person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

Other Categories Disabled Individual any person who:

o Has a physical or mental impairment that substantially limits one or more major life activity(ies) o Has a record of such an impairment; or o Is regarded as having such an impairment.

Veteran: An individual who served in the military during time of war.

Gender: Indicate whether male or female.

EEO 101 (01/15) Page 2 of 2