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New Employee Information Request Form - POSITION QUESTIONNAIRE FOR

By Amanda Phillips,2014-06-17 05:29
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New Employee Information Request Form - POSITION QUESTIONNAIRE FOR ...

    Today’s Date The University of Texas at San Antonio

     / / New Employee Information Request Form

    With few exceptions you have the right to request, receive, review and correct information about yourself collected using this form. Employee Name: EID: Marital Status: Married Single Gender: Male Female Birth Date: / /

    EEO Minority Code:

     Question One: Are you Hispanic or Latino? (a person of Cuban, Mexican, Question Two: Please select the Puerto Rican, South or Central America, or other Spanish culture or racial category or categories with whch

    you most closely identify. Check as many origin, regardless of race). Yes No as apply. -American Indian or Alaskan native ? If you answered “Yes” to Question One, then Question Two is optional. -Asian You can stop here or proceed to Question Two at your discretion. -Black or African American ? If you answered “No” to Question One, please answer Question Two. -Native Hawaiian or

     Other Pacific Islander

     -White Highest Less than high school Baccalaureate Degree Special professional Education High School / GED Master’s Degree (M.D., D.V.M., etc) (Please Level: Associates Degree Doctoral Degree specify)

    Veteran Statuses U.S. Citizen:

    (Please review the definitions on page 2 of this document. Yes No Check all that apply) If No, enter Visa information below) I am not a veteran or a surviving spouse of a veteran or an orphan of a veteran. Visa Type: Texas Veteran Federal Veteran Categories Exp. Date: / / (Please respond in sections A and B) Information Section A - Categories under Categories under Section B - MM / DD / YYYY Vietnam Era Veterans’ Readjustment Jobs for Veterans Act of 2002 Veteran Assistance Act of 1974 Surviving Spouse of Military Service Dates Vietnam Era Armed Veteran Please provide Military Service dates if either Special Disabled Veteran Forces Service Medal Orphan of Newly Separated Veteran status or Recently Other Protected Veteran Veteran a Veteran Separated Veteran status is selected. Newly Separated Veteran Disabled Veteran From: / Other Protected Veteran Veter

     To: / MM / an

     Recently Separated YYYY Prior Texas State Service: Note: Prior State Service could impact your Longevity Pay and Vacation

    Leave

    Previously employed by a Texas State agency: Yes No

    (If yes, include any previous Last Names used; Provide dates and agency e.g. 01/01/03 05/31/05 UT Austin)

    Service with Independent School Districts, Junior Colleges, and/or Community Colleges does not qualify for State service Are you or have you contributed to Teacher Retirement System (TRS) within the past 4? months? Yes No

    Primary Emergency Contact - (Include Area Code) Secondary Emergency Contact - (Include Area

    Code)

     Name: Name:

    U.S.A. U.S.A. Wk Hm Wk Hm Contact Ph: Contact Ph:

     Relationship: Relationship:

    New Employee Contact Information

    Employee Employee Include Street Address, City, State and Zip Code ( ) - Home Home Address Telephone area code number Revised: March 2010 \hr\docs\NewEmployeeInformationReqForm.doc

     1. Yes, I want my personal information 2. No, I do not want any of my information to be treated as confidential. to be confidential.

    Please read and SIGN page 2 of this form before returning it.

    To expedite employment processing with The University of Texas at San Antonio it is necessary for you to complete this form. Items on marked with an asterisk (*) are necessary to facilitate the Affirmative Action Program for the Employment and Advancement in Employment of individuals with disabilities, Disabled Veterans and Veterans of the Vietnam Era. You are not obliged to respond to the asterisked items; however, your response is important to the House Bill 1718 gives you the right to choose whether The University of Texas at San Antonio should allow public access to your home address, home telephone number, Social Security success of our Affirmative Action Program and in meeting state reporting requirements. Any information you provide will remain confidential in accordance number, and whether you have family members. If you do not declare this personal information as confidential, it will be open to the public.with applicable federal regulations. In the space following disability response please indicate nature of impairment. You are also requested to indicate the racial or ethnic group with which you choose identity. This information will be used as statistical data for compliance with state and federal regulations and is required by the Affirmative Action Program. Your employment will not be adversely affected by any information you furnish. The following definitions are provided for your information and assistance in completing the Employee Personal Data form:

    Section A: Categories under Vietnam Era Veterans' Readjustment Ethnicity / Race Assistance Act of 1974 (continued) ? Hispanic or Latino: A person of Cuban, Mexican, Puerto Special Disabled Veteran Rican, South or Central American, or other Spanish culture or A person who: (i) is a veteran of the U.S. military, ground, naval origin, regardless of race. or air service who is entitled to compensation (or who but for the ? American Indian or Alaska Native: A person having origins receipt of military retired pay would be entitled to compensation) in any of the original peoples of North and South America under laws administered by the Department of Veterans' Affairs (including Central America) who maintains cultural for a disability, and is (a) rated at 30 percent or more, or (b) rated identification through tribal affiliation or community at 10 or 20 percent in the case of a veteran who has been attachment. determined under Section 38, U.S.C. 3106, to have a serious ? Asian: A person having origins in any of the original peoples of employment handicap, or (ii) was discharged or released from the Far East, Southeast Asia, or the Indian Subcontinent, active duty because of a service-connected disability. including, for example, Cambodia, China, India, Japan, Korea, Newly Separated Veteran Malaysia, Pakistan, the Philippine Islands, Thailand, and Any veteran who served on active duty in the U.S. military, Vietnam. ground, naval or air service during the one-year period beginning ? Black or African American: A person having origins in any of on the date of such veteran's discharge or release from active the black racial groups of Africa. duty. ? Native Hawaiian or Other Pacific Islander: A person having Other Protected Veteran origins in any of the original peoples of Hawaii, Guam, Samoa, Veterans who served on active duty in the U.S. military, ground, or other Pacific Islands. naval or air service during a war or in a campaign or expedition

    for which a campaign badge has been authorized. A complete list ? White: A person having origins in any of the original peoples of of campaigns can be viewed at: Europe, the Middle East, or North Africa. http://www.opm.gov/veterans/html/vgmedal2.htm Texas Veteran Information

    Veteran: A veteran is defined as an individual who served in the

    military for not less than 90 consecutive days during a national

    emergency declared in accordance with federal law or was Section B: Categories under Jobs for Veterans Act of 2002 discharged from military service for an established service-

    connected disability, AND was honorably discharged from Disabled Veteran: A person who is: (A) a veteran of the U.S. military service and is competent. military, ground, naval, or air service who is entitled to Surviving Spouse of a Veteran: A person who is the spouse of compensation (or who but for the receipt of military retired pay a veteran who has not remarried and is competent, AND the would be entitled to compensation) under the laws administered veteran served in the military for not less than 90 consecutive by the Secretary of Veterans Affairs, or (B) a person who was days during a national emergency and was killed while on active discharged or released from active duty because of a service-duty. connected disability. Orphan of a Veteran: A person who is the child of a veteran who Armed Forces Service Medal Veteran: Any veteran who, while is competent, AND the veteran served in the military for not less serving on active duty in the U.S. military, ground, naval, or air than 90 consecutive days during a national emergency and who service, participated in a United States military operation for which was killed while on active duty. an Armed Forces service medal was awarded pursuant to

    Executive Order No. 12985 Federal Veteran Category Definitions Recently Separated Veteran: Any veteran during the three-year Section A: Categories under Vietnam Era Veterans' Readjustment period beginning on the date of such veteran's discharge or Assistance Act of 1974 release from active duty in the U.S. military, ground, naval, or air

    service. Vietnam Era Veteran: A veteran, any part of whose active U.S. Other Protected Veteran: A veteran who served on active duty in military, ground, naval, or air service was during the period the U.S. military, ground, naval, or air service during a war or in a February 28, 1961 to May 7, 1975 in the Republic of Vietnam or campaign or expedition for which a campaign badge has been August 5, 1964 to May 7, 1975 elsewhere who: (i) served on authorized, under the laws administered by the Department of active duty for a period of more than 180 days, and was Defense. discharged or released with other than a dishonorable discharge; Military Service Dates: Last dates of service in the military. or (ii) was discharged or released from active duty because of a Required for Newly Separated Veteran and Recently Separated service-connected disability if any part of such duty was

    Revised: March 2010 \hr\docs\NewEmployeeInformationReqForm.doc

    performed between the dates cited. Veteran statuses. I have read and understand this material and I certify that the information provided by me is true and correct to the best of my knowledge. This document is executed in good faith.

Employee Signature Date

    The University of Texas at San Antonio is an equal employment opportunity and affirmative action employer.

    Revised: March 2010 \hr\docs\NewEmployeeInformationReqForm.doc

    OTHER VETERAN STATUS CRITERIA

    DATES DATES CAMPAIGN / CAMPAIGN / EXPEDITION EXPEDITION START END START END Campaign or Service Medals Armed Forces Expeditionary Medal (AFEM) (continued) Army Occupation of Austria 05/09/45 07/27/55 Iraq (Northern Watch) 01/01/97 Present Army Occupation of Berlin 05/09/45 10/02/90 Iraq (Desert Spring) 12/31/98 12/31/02 Army Occupation of Germany 05/09/45 05/05/55 Korea 10/01/66 06/30/74 Army Occupation of Japan 09/03/45 04/27/52 Kosovo 03/24/99 Present China Service 07/07/37 09/07/39 Laos 04/19/61 10/07/62 China Service Medal (Extended) 09/02/45 04/01/57 Lebanon 07/01/58 11/01/58 Korean Service 06/27/50 07/27/54 Lebanon 06/01/83 12/01/87 Kosovo Campaign Medal (KCM) Libyan Area 04/12/86 04/17/86

     Operation Allied Force 03/24/99 06/10/99 (Eldorado Canyon)

    Kosovo Campaign Medal (KCM) 06/11/99 To be Mayaguez Operation 05/15/75 05/15/75 determined Operation Joint Guardian

    Kosovo Campaign Medal (KCM) Panama 12/20/89 01/31/90

     Operation Allied Harbor 04/04/99 09/01/99 (Just Cause)

    Kosovo Campaign Medal (KCM) 04/04/99 07/10/99 Persian Gulf 07/24/87 08/01/90

     Operation (Earnest Will)

    Sustain Hope/Shining

    Hope

    Kosovo Campaign Medal (KCM) 03/24/99 07/20/99 Persian Gulf 11/11/98 12/22/98

     Operation Noble Anvil (Desert Thunder)

    Kosovo Campaign Medal (KCM) 04/05/99 06/24/99 Persian Gulf (Desert Fox) 12/16/98 12/22/98

     Task Force Hawk

    Kosovo Campaign Medal (KCM) 03/31/99 07/08/99 Persian Gulf 12/01/95 Present

     Task Force Saber (Southern Watch)

    Kosovo Campaign Medal (KCM) 06/11/99 To be Persian Gulf 12/01/95 02/15/97 determined Task Force Falcon (Vigilant Sentinel)

    Kosovo Campaign Medal (KCM) 04/01/99 11/01/99 Persian Gulf 12/01/95 Present

     Task Force Hunter Intercept Operation

    Quemoy and Matsu Navy Occupation of Trieste 05/09/45 10/25/54 08/23/58 06/01/63 Islands

    Navy Occupation of Austria 05/08/45 10/25/55 Somalia (Restore Hope 12/05/92 03/31/95

    & United Shield)

    Navy Occupation of Berlin 05/08/45 10/02/90 Taiwan Straits 08/23/58 01/01/59 Navy Units of the Sixth Fleet 05/09/45 10/25/55 Thailand 05/16/62 08/10/62 SW Asia Service Medal 08/02/90 11/02/95 Vietnam and Thailand 07/01/58 07/03/65

     (Desert Shield/Storm)

    Vietnam Service Medal (VSM) 07/04/65 03/28/73 Vietnam 04/29/75 04/30/75

    Evacuation (Frequent

    Wind)

    Armed Forces Expeditionary Medal (AFEM) Navy Expeditionary Medal and Marine Corps Expeditionary Medal Berlin 08/14/61 06/01/63 Cuba 01/03/61 10/23/62 Bosnia (Joint Endeavor, 11/20/95 Present Indian Ocean/Iran 11/21/79 10/20/81

     Joint Guard & Joint Forge)

    Cambodia 03/29/73 08/15/73 Iranian/Yemen/Indian 12/08/78 06/06/79

    Ocean

    Cambodia Evacuation 04/11/75 04/13/75 Lebanon 08/20/82 05/31/83

     (Eagle Pull)

    Congo 07/14/60 09/01/62 Liberia (Sharp Edge) 08/05/90 02/21/91 Congo 11/23/64 11/27/64 Libyan Area 01/20/86 06/27/86

    12/19/86 Cuba 10/24/62 06/01/63 Panama 04/01/80 Dominican Republic 04/28/65 09/21/66 Panama 02/01/90 06/13/90 El Salvador 01/01/81 02/01/92 Persian Gulf 02/01/87 07/23/87 Grenada (Urgent Fury) 10/23/83 11/21/83 Rwanda (Distant Runner) 04/07/94 04/18/94 Haiti (Uphold Democracy) 09/16/94 03/31/95 Thailand 05/16/62 08/10/62 Revised: March 2010 \hr\docs\NewEmployeeInformationReqForm.doc

- Continued next column top -

Revised: March 2010 \hr\docs\NewEmployeeInformationReqForm.doc

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