CONNECTICUT DEPARTMENT OF TRANSPORTATION MAINTENANCE INTERVIEW FORM

New Hire and/or InterAgency Recruitment

(Page 1)

Please read directions below before completing this form. Print Clearly.
  1. Complete this form during the interview. Apply the same interviewing criteria for all applicants being interviewed.
  2. Questions listed are intended as guides and should be answered if they relate to the specific job for which interviews are being conducted.
Complete the "Overall Rating Section" as indicated.
Title Interviewed for: / Employment / Transfer
Applicant Name:
Present Class: / Seniority: “YY/MM/DD” / //
Address:
Home Phone#: / ( ) - / CellPhone#: / () -
Date/Time of Interview: / // / Interviewer's Name:

Discuss the applicable items in this section and check off:

Title of position, essential requirements of the job and salary: Working Conditions

Winter Storm Policy:Sick Leave Policy: Drug & Alcohol Policy:

Policy NO. EX.O. - 26 Employment of Relatives:

This position requires mandatory overtime during the snow and ice season.Do you have any obligations that would interfere or conflict with this responsibility?______

Are you currently employed with any consultant, contractor, appraiser, or any other organization or individual which is under contract or agreement with the State of Connecticut, or who may be doing business with the State of Connecticut, which could cause, or create the appearance of, a conflict with or influence the performance of your duties with the Department as they were explained to you?

Yes No If yes, explain the potential conflict and provide details re: name, address,
etc. of the company/individual/organization: ______

______

Travel Distance to work:______Approximate Commute Time:______

The essential functions/duties of the job have been described to you.
Are you able to perform them with or without an accommodation? Yes No

Are you presently legally authorized to work full time in the United States? ______

Do you read, write and understand English? ______

CONNECTICUT DEPARTMENT OF TRANSPORTATION MAINTENANCE INTERVIEW FORM

New Hire and/or InterAgency Recruitment

(Page 2)

Questions to be asked ONLY when interviewing/hiring into positions requiring a Commercial Drivers License (CDL):

Have you ever tested positive for drugs? ______

Have you ever tested positive for alcohol? ______

If yes, have you successfully completed the Return-to-Duty process, which includes, evaluation by a Substance Abuse Professional (SAP) as a result of any positive test results? ______

(Documentation will have to be provided by applicant prior to being considered for employment)

Education & Training:

Highest grade completed: ______College Degree: Yes NoType:______Major:______

Technical/Business School: No Yes Specify:______

Technical/Military Service: No Yes Specify:______

Previous State Service: No Yes Specify:______

______
Describe your experience/training with computers and types of computer applications (if applicable):______
Licenses:

Commercial Driver’s License:Class: ______Endorsements (Airbrakes, Tanker): ______

How long have you had a CDL? ______
Describe your CDL Driving Experience (type of vehicles driven)______

______

Medical Examiners Card: Yes No Date of Expiration:______

Explain any accidents with your Commerical Driver’s License (CDL) while on the job: ______

______

Do you have any special licenses (Welding, Electrical): (Attach copy)______

______

Describe your experience operating various pieces of equipment(type/how long): ______

______

Have you had any accidents/incidents while on the job which resulted in damage to equipment?
If so, please describe:______
______Describe your experience with equipment repair and the types ofequipmentworked on (how long):______

CONNECTICUT DEPARTMENT OF TRANSPORTATION MAINTENANCEINTERVIEW FORM

New Hire and/or InterAgency Recruitment

(Page 3)

Work History:

Explain any experience you may have with regard to snow plowing operations: ______

______

______

What other experience or education do you have that relates to the duties previously described
to you? ______
______

Explain reasons for any breaks in youremployment history: ______
______

Explain reasons for any termination(s) from previous employment: ______
______

Were you ever disciplined by an employer? If so, explain: ______

______

Have you ever exhibited any inappropriate or violent behavior related to the workplace?

If so, explain: ______

______

How would DOT benefit from hiring you? ______

______

______

Do you have any concerns that would preclude you from accepting this position if it were

offered to you? ______

Do you have any questions for the panel? ______

______

Is there any additional information you would like to add?______
______
______

Geographic Preferences:

Admin. Office Rocky Hill(D1) Norwich(D2) New Haven(D3) Thomaston(D4)

None Other:______

(include relocation information)

OVERALL RATING SECTION
Eligible for Appointment Not eligible for Appointment
Interviewer's Printed Name and Title: ______- ______
Interviewer's Signature: ______

Rev. 12/10