STATE OF ILLINOIS LEGAL DIVISION - PUBLIC CONTRACTS UNIT Department of Human Rights 100 W. RANDOLPH - SUITE 10-100 CHICAGO, ILLINOIS 60601 TELEPHONE: 312-814-2432 (TDD: 312-263-1579) EMPLOYER REPORT FORM Please read instructions before completing this form. Improperly completed forms will not be processed. Use black or dark blue ink. Do not use pencil. Type or print legibly. Return the completed form to the above address. SECTION I. PURPOSE FOR WHICH REPORT IS FILED Initial registration for contract eligibility Renewal registration ⇒ IDHR number is SECTION II. TYPE OF REPORT SUBMITTED (Check one only) SINGLE-ESTABLISHMENT REPORT. This employer conducts its operations from a single location. This report contains employment figures for that location. MULTI-ESTABLISHMENT CONSOLIDATED REPORT. This employer operates from multiple locations. This report is filed by the headquarters and consolidates the employment figures for all locations. (Required for all multiestablishment employers). ESTABLISHMENT REPORT. This report contains the employment figures for the facility identified below. (Required for all multi-establishment employers. A separate establishment report must be filed for each establishment located in Illinois employing 25 or more persons). SECTION III. EMPLOYER IDENTIFICATION A. EMPLOYER’S PRINCIPAL PLACE OF BUSINESS. (Complete for all reports) NAME ADDRESS CITY COUNTY CONTACT PERSON STATE ZIP CONTACT TELEPHONE FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) B. ESTABLISHMENT REPORTING. (Complete for establishment reports only) NAME ADDRESS CITY COUNTY CONTACT PERSON STATE ZIP CONTACT TELEPHONE FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN) SECTION IV. FORM OF ORGANIZATION INDIVIDUAL OR SOLE PROPRIETOR PARTNERSHIP CORPORATION - FOR PROFIT CORPORATION - NOT FOR PROFIT GOVERNMENT ENTITY EDUCATIONAL INSTITUTION OTHER-EXPLAIN BELOW The information requested is necessary to accomplish the statutory purpose set forth in 775 ILCS 5/1-101 et seq. Disclosure of this information is REQUIRED. If you do not complete this form, it will not be processed and you will not be eligible to be awarded public contracts. This form has been approved by the Forms Management Center. In compliance with state and federal constitutions, the Illinois Human Rights Act, the U.S. Civil Rights Act, Sections 503 and 504 of the Federal Rehabilitation Act, and the Americans with Disabilities Act, the Department of Human Rights does not unlawfully discriminate in employment, contracts, or any other activity. IL 442-0010 (IDHR FORM PC-1 rev. 06/2007) PAGE 1 OF 6 American LegalNet, Inc. www.FormsWorkflow.com SECTION V. WORKFORCE INFORMATION SEE THE INSTRUCTIONS BEFORE COMPLETING THIS SECTION. JOB CATEGORIES (A) OVERALL TOTALS M (B) F (C) WHITE (Not of Hispanic Origin) M (D) F (E) BLACK OR AFRICANAMERICAN (Not of Hispanic Origin) M F (F) (G) HISPANIC OR LATINO M (H) F (I) ASIAN OR PACIFIC ISLANDER AMERICAN INDIAN OR ALASKAN NATIVE M (J) M (L) F (K) F (M) Officials & Managers Professionals Technicians Sales Workers Office & Clerical Craft Workers (Skilled) Operatives (Semi-Skilled) Laborers (Unskilled) Service Workers TOTAL M = MALE. COLUMN B IS SUM OF ROWS D,F,H,J AND L. F = FEMALE. COLUMN C IS SUM OF ROWS E,G, I,K, AND M. CHECK THIS BOX ONLY IF REGISTRANT DID NOT EMPLOY ANY INDIVIDUALS AT TIME OF REGISTRATION. DATE OF ABOVE DATA _______________________________________ SECTION VI. GENERAL INFORMATION NOTE: ANSWER EACH QUESTION BELOW WITH INFORMATION PERTAINING TO THE WORK FORCE REPORTED ABOVE. A. DESCRIBE THE GOODS OR SERVICES PRODUCED AT OR PROVIDED BY THE EMPLOYER. B. IDENTIFY THE EMPLOYER’S THREE DIGIT STANDARD INDUSTRIAL CLASSIFICATION (SIC) CODE, IF KNOWN. C. IS THE EMPLOYER A FEDERAL CONTRACTOR PURSUANT TO FEDERAL EXECUTIVE ORDER 11246? D. DOES THE COMPANY NORMALLY HIRE ADDITIONAL EMPLOYEES TO PERFORM CONTRACT WORK? E. WHAT IS THE MAXIMUM NUMBER OF EMPLOYEES WORKING FOR THE COMPANY DURING A 12-MONTH PERIOD? F. WHAT IS THE AVERAGE NUMBER OF PERSONS EMPLOYED BY THE COMPANY ON A YEAR-ROUND BASIS? G. IDENTIFY THE GEOGRAPHICAL AREA FROM WHICH THE COMPANY DRAWS ITS EMPLOYEES. USE CITY, COUNTY, METROPOLITAN STATISTICAL AREA, OR DISTANCE FROM ESTABLISHMENT. H. WITHIN THE PAST THREE YEARS, HAS THE COMPANY BEEN DECLARED INELIGIBLE FOR ANY PUBLIC CONTRACT BASED ON A FINDING OF EMPLOYMENT DISCRIMINATION? IF YES, ATTACH A SEPARATE SHEET FULLY EXPLAINING THE SITUATION. I. DOES THE COMPANY HAVE A CURRENT WRITTEN AFFIRMATIVEACTION PLAN? SECTION VII. CERTIFICATION I certify that the information provided in this report, and in any attachments thereto, is true and accurate to the best of my knowledge and belief. The employer filing this report agrees to conform with the requirements set forth in the Illinois Human Rights Act, 775 ILCS 5/1-101 et seq., and the rules and regulations of the Department of Human Rights. I am authorized to sign this form on behalf of the employer. SIGNATURE TYPED NAME AND TITLE TELEPHONE NUMBER DATE IL 442-0010 (IDHR FORM PC-1 rev. 06/2007) PAGE 2 OF 6 American LegalNet, Inc. www.FormsWorkflow.com ILLINOIS DEPARTMENT OF HUMAN RIGHTS LEGAL DIVISION - PUBLIC CONTRACTS UNIT SECTION I INSTRUCTIONS FOR COMPLETING THE EMPLOYER REPORT FORM KEEP THESE INSTRUCTIONS FOR FUTURE REFERENCE. THEY CONTAIN IMPORTANT INFORMATION REGARDING YOUR DUTIES AND OBLIGATIONS AS A PUBLIC CONTRACTOR. INITIAL REGISTRATION. Check this box if the company you are registering has not previously registered with IDHR. RENEWAL REGISTRATION. Check this box if this is a registration renewal and list your IDHR number. SECTION II NEED HELP? Call us. We can be reached at 312-814-2431 Monday through Friday, 8:30 AM to 5:00 PM, Central Time. We will make every effort to assist you in obtaining a prompt and accurate answer to your question. (TDD: 312-2631579) GENERAL Before completing this section, it may be necessary to make or obtain additional copies of page one and two of the form. A separate report must be filed for each location required to report. The following examples illustrate typical filing situations. • A machine shop with 18 employees in Marion, Illinois, and no other locations, will file a single establishment report. • A computer retailer headquartered in Chicago employs 75 persons statewide. Forty are employed in Chicago, 25 are employed in Rockford, and 10 are located in Peoria. This company will file three reports: a Consolidated Report listing its statewide employees; an Establishment Report listing its Chicago employees, and an Establishment Report listing its Rockford employees. A report for the Peoria location is not required because fewer than 25 persons are employed. • Corporation XYZ , headquartered in Boston, has 30 separate facilities located throughout the US. Three are located in Illinois, each employing 25 or more persons. The corporation will file four reports: a Consolidated Report covering all employees nationwide and three Establishment Reports, one for each Illinois location. • If one of these situations does not apply, please contact IDHR at the number listed in the box above. LEGAL AUTHORITY. The filing requirement is authorized under 44 Ill. Admin. Code 750.210(a). WHO MUST FILE. You must file if any one of the following applies: 1) your company employs 15 or more persons at the time of application for a public contract; 2) your company has employed 15 or more persons at any time during the 365 day period prior to the date of your applying for a public contract; 3) you are directed to file by a contracting agency of the State of Illinois, any political subdivision, or a municipal corporation. WHEN THE FORM MUST BE FILED. This depends on the procurement method used by the contracting agency. 1) If the contract will be awarded by means of COMPETITIVE BIDDING OR A COMPETITIVE SELECTION PROCEDURE, a properly completed form must be on file with IDHR prior to bid opening. 2) If the contract will be awarded by use of any other procurement method, the form must be on file with IDHR prior to contract award. WHEN A FORM IS PROPERLY FILED. A form is deemed filed when it is received, in IDHR’s Chicago office, properly completed and signed. Please note, writing “applied for” on a bid does not satisfy the filing requirement; the form must be on file with IDHR and must be properly completed and signed.. SECTION III Single establishment employers should complete Section A only. Multiple-establishment employers should complete both Sections A and B. All reports for such employers should be filed by the headquarters on behalf of its various locations. All forms received by IDHR directly from establishment locations are deemed to have been filed by the headquarters entity. FEIN numbers must be provided. Sole proprietors may use their social security number in lieu of a FEIN number and should so indicate. IL 442-0010 (IDHR FORM PC-1 rev. 06/2007) PAGE 3 OF 6 American LegalNet, Inc. www.FormsWorkflow.com SECTION IV Check the appropriate box. SECTION V EMPLOYMENT DATA IS REQUIRED. Forms received with employment data omitted will not be processed. The gathering and retention of employee race/ethnicity and gender data is permitted by state and federal law so long as such data are kept separate from other personnel information and are not used for the purpose of committing unlawful discrimination. DEFINITION OF EMPLOYEE. For purposes of this form, an “employee” is an individual performing services for remuneration for the employer. All full-time and permanent part-time employees are to be reported. COUNT EMPLOYEES ONCE. Report each employee in only one job category. (See below). Within that category, report each employee in only one box reflecting the person’s race/ethnicity and gender. (See below). CHECK YOUR MATH. Total each column. Within rows, boxes marked M (Male) must total to Column B and all boxes marked F (Female) must total to Column C. Forms received containing errors will not be processed. SPECIAL NOTE FOR COMPANIES WHO FILE EEO-1 REPORTS. If your company files Standard Form 100 (EEO-1) with the federal Joint Reporting Committee, you will find that the job, race/ethnic, and gender categories, parallel those used in the EEO-1 form. DESCRIPTION OF RACE/ETHNIC CATEGORIES Race/ethnic designations as used by the Department 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 report 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 or African-American (Not of Hispanic Origin). All persons having origins in any of the Black racial groups of Africa. Hispanic or Latino. All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. Asian or Pacific Islander. All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa. American Indian or Alaskan Native. All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. DESCRIPTION OF JOB CATEGORIES Each employee should be counted in only one job category. Select the category containing the jobs most similar to that performed by the employee. The jobs listed in each category are intended to provide examples, not a complete list, of all job titles falling into that category. Officials and Managers. Occupations requiring administrative and managerial personnel who set broad policies, exercise overall responsibility for execution of these policies, and direct individual departments or special phases of a firm's operations. Includes: officials, executives, middle management, plant managers, department managers, and superintendents, salaried supervisors who are members of management, purchasing agents and buyers, railroad conductors and yard masters, ship captains, mates and other officers, farm operators and managers, and kindred workers. Professionals. Occupations requiring either college graduation or experience of such kind and amount as to provide a comparable background. Includes: accountants and auditors, airplane pilots and navigators, architects, artists, chemists, designers, dietitians, editors, engineers, lawyers, librarians, mathematicians, natural scientists, registered professional nurses, personnel and labor relations specialists, physical scientists, physicians, social scientists, teachers, surveyors and kindred workers. Technicians. Occupations requiring a combination of basic scientific knowledge and manual skill which can be obtained through 2 years of post high school education, such as is offered in many technical institutes and union colleges, or through equivalent on-the-job training. Includes: computer programmers, drafters, engineering aides, junior engineers, mathematical aides, licensed, practical or vocational nurses, photographers, radio operators, scientific assistants, technical illustrators, technicians (medical, dental, electronic, physical science), and kindred workers. Sales. Occupations engaging wholly or primarily in direct selling. Includes: advertising agents and sates workers, insurance agents and brokers, real estate agents and brokers, stock and bond sales workers, demonstrators, sales workers and sales clerks, grocery clerks, and cashiers/checkers, and kindred workers. IL 442-0010 (IDHR FORM PC-1 rev. 06/2007) PAGE 4 OF 6 American LegalNet, Inc. www.FormsWorkflow.com Office and Clerical. Includes all clerical-type work regardless of level of difficulty, where the activities are predominantly nonmanual though some manual work not directly involved with altering or transporting the products is included. Includes: bookkeepers, collectors (bills and accounts), messengers and office helpers, office machine operators (including computer), shipping and receiving clerks, stenographers, typists and secretaries, telegraph and telephone operators, legal assistants, and kindred workers. Craft Workers (skilled). Manual workers of relatively high skill level having a thorough and comprehensive knowledge of the processes involved in their work. Exercise considerable independent judgment and usually receive an extensive period of training. Includes: the building trades, hourly paid supervisors and lead operators who are not members of management, mechanics and repairers, skilled machining occupations, compositors and typesetters, electricians, engravers, painters (construction and maintenance), motion picture projectionists, pattern and model makers, stationary engineers, tailors and tailoresses, arts occupations, handpainters, coaters, bakers, decorating occupations, and kindred workers. Operatives (semiskilled). Workers who operate machine or processing equipment or perform other factory-type duties of intermediate skill level which can be mastered in a few weeks and require only limited training. Includes: apprentices (auto mechanics, plumbers, bricklayers, carpenters, electricians, machinists, mechanics, building trades, metalworking trades, printing trades, etc.), operatives, attendants (auto service and parking), blasters, chauffeurs, delivery workers, sewers and stitchers, dryers, furnace workers, heaters, laundry and dry cleaning operatives, milliners, mine operatives and laborers, motor operators, oilers and greasers (except auto), painters (manufactured articles), photographic process workers, truck and tractor drivers, knitting, looping, taping and weaving machine operators, welders and flame cutters, electrical and electronic equipment assemblers, butchers and meatcutters, inspectors, testers and graders, handpackers and packagers, and kindred workers. Laborers (unskilled). Workers in manual occupations which generally require no special training who perform elementary duties that may be learned in a few days and require the application of little or no independent judgment. Includes: garage laborers, car washers and greasers, groundskeepers and gardeners, farmworkers, stevedores, wood choppers, laborers performing lifting, digging, mixing, loading and pulling operations, and kindred workers. Service Workers. Workers in both protective and nonprotective service occupations. Includes: attendants (hospital and other institutions, professional and personal service, including nurses aides, and orderlies), barbers, char workers and cleaners, cooks, counter and fountain workers, elevator operators, firefighters and fire protection, guards, doorkeepers, stewards, janitors, police officers and detectives, porters, waiters and waitresses, amusement and recreation facilities attendants, guides, ushers, public transportation attendants, and kindred workers. SECTION VI A. In this box, briefly describe what products are made and/or what services are provided at the establishment whose workforce is reported above. Please be specific. B. If known, enter the three digit SIC code. If not known, leave this section blank. C. Answer “yes” or “no.” In general, a person holding a contract with any agency of the federal government valued at $10,000 or more is a covered federal contractor. D. Answer “yes” or “no” as appropriate. E. Enter a number that represents the greatest number of persons employed at the establishment at any one time during a typical 12-month period. F. Enter a number representing the average number of persons employed per month during a 12-month period. G. Filers should determine the area from which most of its employees are drawn. This can be expressed as a city, county, metropolitan statistical area, or a linear distance from the reported establishment. H. For purposes of answering this question, a finding of ineligibility is defined as a final order of a court of record of the United States or any state, or any federal or state administrative agency. Full details must be provided. AN ANSWER OF “YES” TO THIS QUESTION MAY AFFECT THE FILER’S ELIGIBILITY TO BE AWARDED PUBLIC CONTRACTS IN ILLINOIS. I. Answer “yes” or “no.” While it is not necessary to forward a copy of such a plan to IDHR with this report, filers should be aware that the Department may require that any public contractor or eligible bidder file an affirmative action plan. (See EEO Clause below). SECTION VII Before signing the form, the responsible party should read the EEO Clause, (see below). This Clause found at 44 Ill. Admin. Code 750.APPENDIX A, is incorporated into all Illinois public contracts and summarizes the duties and obligations of public contractors and eligible bidders with respect to non-discrimination and affirmative action in connection with public contracts. The sexual harassment policy notice and Discriminatory Club Act notice should also be read. FILING THE FORM Completed and signed forms should be mailed or delivered to the address given on the top of page one of the form. Do not send the form to the contracting agency as doing this may delay processing. Please file only pages one and two of the form. Keep the instruction pages for future reference. IL 442-0010 (IDHR FORM PC-1 rev. 06/2007) PAGE 5 OF 6 American LegalNet, Inc. www.FormsWorkflow.com ________________ ILLINOIS ADMINISTRATIVE CODE EQUAL EMPLOYMENT OPPORTUNITY CLAUSE 44 Ill. Admin. Code 750. APPENDIX A. Equal Employment Opportunity Clause EQUAL EMPLOYMENT OPPORTUNITY In the event of the contractor's non-compliance with the provisions of this Equal Employment Opportunity Clause, the Illinois Human Rights Act or the Rules and Regulations of the Illinois Department of Human Rights ("Department"), the contractor may be declared ineligible for future contracts or subcontracts with the State of Illinois or any of its political subdivisions or municipal corporations, and the contract may be canceled or voided in whole or in part, and such other sanctions or penalties may be imposed or remedies invoked as provided by statute or regulation. During the performance of this contract, the contractor agrees as follows: 1) That it will not discriminate against any employee or applicant for employment because of race, color, religion, sex, marital status, national origin or ancestry, age, physical or mental handicap unrelated to ability, or an unfavorable discharge from military service; and further that it will examine all job classifications to determine if minority persons or women are underutilized and will take appropriate affirmative action to rectify any such underutilization. 2) That, if it hires additional employees in order to perform this contract or any portion thereof, it will determine the availability (in accordance with the Department's Rules) of minorities and women in the area(s) from which it may reasonably recruit and it will hire for each job classification for which employees are hired in such a way that minorities and women are not underutilized. 3) That, in all solicitations or advertisements for employees placed by it or on its behalf, it will state that all applicants will be afforded equal opportunity without discrimination because of race, color, religion, sex, marital status, national origin or ancestry, age, physical or mental handicap unrelated to ability, or an unfavorable discharge from military service. 4) That it will send to each labor organization or representative of workers with which it has or is bound by a collective bargaining or other agreement or understanding, a notice advising such labor organization or representative of the contractor's obligations under the Illinois Human Rights Act and the Department's Rules. If any such labor organization or representative fails or refuses to cooperate with the contractor in its efforts to comply with such Act and Rules, the contractor will promptly so notify the Department and the contracting agency and will recruit employees from other sources when necessary to fulfill its obligations thereunder. 5) That it will submit reports as required by the Department's Rules, furnish all relevant information as may from time to time be requested by the Department or the contracting agency, and in all respects comply with the Illinois Human Rights Act and the Department's Rules. 6) That it will permit access to all relevant books, records, accounts and work sites by personnel of the contracting agency and the Department for purposes of investigation to ascertain compliance with the Illinois Human Rights Act and the Department's Rules. 7) That it will include verbatim or by reference the provisions of this clause in every subcontract it awards under which any portion of the contract obligations are undertaken or assumed, so that such provisions will be binding upon such subcontractor. In the same manner as with other provisions of this contract, the contractor will be liable for compliance with applicable provisions of this clause by such subcontractors; and further it will promptly notify the contracting agency and the Department in the event any subcontractor fails or refuses to comply therewith. In addition, the contractor will not utilize any subcontractor declared by the Illinois Human Rights Commission to be ineligible for contracts or subcontracts with the State of Illinois or any of its political subdivisions or municipal corporations. _________________________ WRITTEN SEXUAL HARASSMENT POLICY REQUIRED Illinois law requires all parties to a public contract and all eligible bidders to have a written sexual harassment policy covering their employees and applicants for employment. This requirement applies regardless of the number of persons employed or the dollar value of any public contract. This requirement is found at 775 ILCS 5/2-105(A)(4). Each sexual harassment policy must contain the following elements: 1. 2. 3. 4. 5. 6. 7. A statement that sexual harassment is illegal. The definition of sexual harassment under the Illinois Human Rights Act. A description of the acts that constitutes sexual harassment, with examples. The vendor's internal complaint procedure, including penalties. The legal recourse, investigative, and complaint process available through the Illinois Department of Human Rights and the Illinois Human Rights Commission. Information as to how a person can contact the Department and the Commission. Information regarding the protection against retaliation under Section 6-101 of the Human Rights Act. A copy of the employer's policy must be submitted to the Department or to a contracting agency upon request. Employers can obtain a Model Sexual Harassment Policy by contacting the Department. ___________________________ DISCRIMINATORY CLUB ACT Pursuant to 775 ILCS 25/2, no private organization selling goods or services to the State or receiving any award or grant from the State, nor any public body, may pay any dues or fees on behalf of its employees or agents or may subsidize or otherwise reimburse them for payments of their dues or fees to any discriminatory club. A “discriminatory club” includes any club, society, organization, or association, which discriminates in its membership policy or in access to its services or facilities. Facilities that are distinctly private in nature, such as restrooms and shower rooms, are exempt as to discrimination based on sex. IL 442-0010 (IDHR FORM PC-1 rev. 06/2007) PAGE 6 OF 6 American LegalNet, Inc. www.FormsWorkflow.com