Department of Neurology
Personal Information Worksheet

Contact Information

For questions, please contact Neurology-HR@cuanschutz.edu
Phone: 303-724-3871



Biographical Details

Employee ID (if applicable):
Prefix:
Suffix:
Social Security Number
(national ID): *

Start Date
(in Neurology):

Name must be entered EXACTLY as printed on Social Security Card.

First Name: *
Middle Name/Initial:
Last Name: *
Date of Birth (MM/DD/YYYY): *
Birth Country: *
Birth State: *
Birth Location
(City, Town or Village):*
Gender: *
Female
Male

Highest Education Level: (select one) *

A - Not indicated B - Less than HS Grad C - HS Grad or Equivalent
D - Some College E - Technical School F - 2-Year College Degree
G - Bachelor's Level Degree H - Some Graduate School I - Master's Level Degree
J - Doctorate (Acdemic) K - Doctorate (Professional) L - Post Doctorate
M - Pharmaceutical Chemist N - Specialist in Education

Associate of: (Field) Bachelor of: (Field)
Master of: (Field) Doctor of: (Field)
Certificate of: (Field) Other: (Field)

Contact Information

HOME ADDRESS (Permanent or Foreign Address for Non-Resident International Employees) *
U.S.A.
Other

Address 1: *

Address 2:
City: *
State: *
Postal Code: *

MAILING ADDRESS Same as Home Address

(Permanent or Foreign Address for Non-Resident International Employees)
U.S.A.
Other

For Non-Resident International Employees, mailing address MUST be a local street address (not P.O. Box or foreign address).

Address 1:

Address 2:
City:
State:
Postal Code:

Telephone Numbers:

Cellular: *

Home:
Additional Phone:
Additional Phone Type:
Cellular Pager Fax Other

E-Mail Addresses:

Primary: *

Additional E-Mail:
Additional E-Mail Type:
Business Dorm Home Other

Regional

Ethnic Group: (Selection Required) *

African American
American Indian/Alaskan Native
Asian
Caucasian
Hispanic/Latino
Chose Not to Disclose
Native Hawaiian/ Pacific Islander

Ethnic Group Definitions (Source: Dept. of Equal Opportunity)

African American: Black, not of Hispanic origin. A person having origins in any of the black racial groups of Africa.
American Indian/Alaskan Native: A person having origins in any of the original peoples of North, Central, and South America, and who maintains tribal affiliation or community attachment.
Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia and the Indian Subcontinent. This area includes, for example, China, India, Japan, Korea, Cambodia, Malaysia, Pakistan, Thailand, Vietnam and the Phillippine Islands.
Caucasian: White, not of Hispanic origin. A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic/Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
Chose Not to Disclose: Use when entering ethnicity data for an employee who chooses not to disclose ethnicity information. Ethnicity data is used by the University for numerous reporting requirements and it is requested you complete this information as accurately as possible when entering a new hire.
Native Hawaiian/Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Military Status: (Voluntary Disclosure -- choose "Not Indicated" if unknown*) *

Not Indicated
Active Reserve
Inactive Reserve
Disabled Vet
Vietnam Era Vet
No Military Service
Other Protected Veteran
Disabled Vietnam Era Vet
Retired Military

*Copy of DD214 to be sent to the campus HR office if veteran status is being selected.
Veteran Definition - (source: U.S. Department of Labor, Veterans' Employment and Training. www.dol.gov/vets)Vietnam Era Veteran: (1) Served in the military, ground, naval or air service of the U.S. on active duty for a period of time more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such activity duty occurred: i) in the Republic of Vietnam between 2/28/61 and 5/7/75; or ii) between 8/5/64 and 5/7/75 in all other cases; or (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed: i) in the Republic of Vietnam between 2/28/61 and 5/7/75; or ii) between 8/5/64 and 5/7/75 in all other cases.