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					                                                                                                   Local Agency Request to Fill Form
                                                                                                                 Please complete and submit request to:
                                                                                                                     Virginia Department of Social Services
                                                                                                                 Division of Human Resource Management
           VIRGINIA DEPARTMENT OF SOCIAL SERVICES                                                                                    730 East Broad Street
                                                                                                                                     Richmond, VA 23219
                                                                                                                                 Facsimile: (804) 692-1599

                               To initiate recruitment for a vacant position, please send completed form to
                                        VDSS DHRM by 12:00 noon Wednesday for Friday posting.
                                                  PART I: RECRUITMENT INFORMATION
1. TYPE OF RECRUITMENT REQUESTED (please select one):                    Open             Intra-Agency*               Inter-Agency               Jurisdictional

(*Please note: Intra-Agency postings may not be used when underutilization exists. Please consult VDSS DHRM prior to initiating an Intra-Agency
request.)
2. LENGTH OF THE RECRUITMENT PERIOD (please select one):                                         3. TYPE OF SCREENING (please select one):

      2 weeks              3 weeks             Other (Please specify):                                        Preliminary             Complete
                                                        PART II: POSITION INFORMATION
4. POSITION CLASSIFICATION TITLE:                                5. POSITION NUMBER:                      6. CLASS CODE:       7. GRADE:
   SOCIAL WORKER                                                       00058                                0304000                  10
8. POSITION LOCATION:                                            9. IS THIS A NEW OR ESTABLISHED POSITION?                     10. HOURS/WEEK:
   BEDFORD, VA                                                           New Position             Established position               40
11. APPOINTMENT TYPE:                    Temporary        Restricted (please specify end date):
                                         Full-time         Part-time            Other (please specify):
12. SPECIAL REQUIREMENTS (Please use this space to list any special requirements necessary for this position. This information will appear on the
job
    posting and may be used as part of the screening criteria when determining qualified candidates.) Requires 4 year college degree. Resumes not
accepted unless accompanied by a Virginia State application form.


    13. SALARY OR HOURLY RATE TO BE POSTED ON THE RECRUITMENT ANNOUNCEMENT: $29,416.13
                                                     PART III. LOCAL AGENCY INFORMATION
14. LOCAL AGENCY NAME:                                                          15. LOCAL AGENCY NUMBER (FIPS Code):
    Bedford County Dept. of Social Services                                          019/515
15. CONTACT PERSON/TITLE:                                                       16. TELEPHONE NUMBER (include area code): (540) 586 -7750,x2224
    Patricia C. McCauley/Administrative Manager                                      FACSIMILE NUMBER (include area code):                (540) 587 - 0781
17. HIRING AUTHORITY/TITLE:                                                     18. TELEPHONE NUMBER (include area code): (540) 586 – 7750
    Leighton T. Langford, Jr./Director                                               FACSIMILE NUMBER (include area code):                (540) 587 - 0781


                                                        PART IV: VDSS DHRM USE ONLY
19. DATE REQUEST RECEIVED:                                                      20. DATE VACANCY ANNOUNCED:
21. ANNOUNCEMENT DEADLINE:                                                      22. REANNOUNCEMENT DEADLINE:
23. DATE ENTERED IN HRM TRACK:                            INITIAL:              24. DATE ENTERED INTO ACCESS:                                     INITIAL:
_______                                                                         ______
25. DATE APPLICATIONS SCREENED:                                                 26. DATE CERTIFICATION LIST SENT TO HIRING AUTHORITY:


                                                            PART V: SELECTION DATA
                (This section is to be completed by the hiring authority at the conclusion of the recruitment/selection process.)
27. SELECTED CANDIDATE’S NAME:                                     28. SEX:                            29. RACE:              30. BEGIN DATE:

                                                                                Male
                                                                         Female
31. BEGIN DATE:                                                          32. STARTING SALARY/HOURLY RATE:


33. HIRING AUTHORITY’S SIGNATURE:                                                                             34. DATE:




Revised 12/2002