UNIVERSITY OF MASSACHUSETTS PERSONAL DATA QUESTIONNAIRE

Transcription

1 UNIVERSITY OF MASSACHUSETTS PERSONAL DATA QUESTIONNAIRE Last Name First Name Middle Name Other Name(s) Home Address Line 1 Home Address Line 2 City State Zip Home Telephone Birthdate Marital Status Married Single Widowed Divorced Social Security Number Gender Male Female Person to Notify in Case of Emergency Relationship Last Name First Name Middle Name Home Address Line 1 Home Address Line 2 City State Zip Home Telephone

2 Citizenship Status: US Alien Permanent Naturalized Alien Temporary Citizenship Country Prior Public Employment in Commonwealth of Massachusetts Name From To VISA Type Military Status if Applicable Date of Discharge Veteran of the Vietnam era any person who: (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released with other than a dishonorable discharge; (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975; or (3) served on active duty for more than 180 days and served in the Republic of Vietnam between February 28, 1961 and May 7,1975 Newly Separated Veteran any veteran who served on active duty during the three year period beginning on the date of such veteran's discharge or release from active duty (include date of discharge below) Disabled Veteran any veteran who served on active duty in the U.S. military ground, naval, or air service: (1) is entitled to disability compensation (or who but for the receipt of military retired pay would be entitled to disability compensation) under laws administered by the Secretary of Veterans Affairs; or (2) was discharged or released from active duty because of a service connected disability Other Protected Veteran - any other veteran who served on active duty in the U.S. military ground, naval, or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, other than a special disabled veteran, veteran of the Vietnam era, or recently separated veteran Armed Forces Service Medal Veteran - any veteran who, while serving on active duty in the U.S.

3 military ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order (61 Fed. Reg. 1209) AFFIRMATIVE ACTION SELF IDENTIFICATION FORM The University of Massachusetts Medical School (UMMS) is an Equal Opportunity and Affirmative Action employer. We are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights and regulations. In order to comply with these laws, we invite our new hires to voluntarily self-identify their gender and race/ethnicity information. Submission of this information is completely voluntary. This information will be kept confidential in accordance with state and federal laws, and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations. Race/ Ethnicity (Check one) Hispanic or Latino (All races) - a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. NOT Hispanic or Latino If you did not identify as Hispanic or Latino, then report in the appropriate race category below: Black or African American - a person having origins in any of the Black racial groups of Africa (not Hispanic or Latino) Native Hawaiian or other Pacific Islander - a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands (not Hispanic or Latino) Asian - a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent (not Hispanic or Latino) American Indian or Alaskan Native - a person having origins in any of the original peoples of North America or South America (including Central America), and who maintains tribal affiliations or community attachment (not Hispanic or Latino) White - a person having origins in any of the original peoples of Europe, North Africa, or the Middle East (not Hispanic or Latino) Two or more races - a person having origins in any combination of two or more of the categories above (not Hispanic or Latino) Additional Ethnic Categories: Please choose any additional ethnic definitions that may describe your ethnic background in more detail. Which best describes your ethnic background? Please select one or more, if applicable. Hispanic Central American Cuban Dominican Mexican-American, Mexican, Chicano Other, Hispanic Puerto Rican

4 South American Spanish American Indian/ Alaska Native Alaska Native Alaskan Athabaskans Aleutian American Indian Apache Aquinnah Wampanoag Assonet Wampanoag Blackfoot Cayuga Chappaquidick Wampanoag Cherokee Chappiquidic Wampanoag Chaubunahunga-maug Nipmuck Cheyenne Chickasaw Chippewa Choctaw Comanche Cree Creek Crow Delaware Eskimo Herring Pond Wampanoag Hopi Iroquois Kiowa Lumbee Maliseet Mashpee Wampanoag Mic Mac Mohawk Natick Nipmuck Navajo

5 Nipmuck Nipmuck Nation Oneida Onondaga Osage Other, American Indian/ Alaska Native Paiute Pima Pocassett Wampanoag Ponkapoag Potawatomi Pueblo Puget Sound Salish Seaconke Wampanoag Seminole Seneca Shoshone Sioux Tlingit Tohono O Odham Tuscarora Wampanoag Yaqui Asian Asian Indian Banglideshi Cambodian Chinese Filipino Hmong Indian Indonesian Japanese Korean Laotian Malaysian Other Southeast Asian

6 Other, Asian Pakistani Sri Lankan Taiwanese Thai Turkish Vietnamese Black/ African American African Black or African American Brazilian, Black Cape Verdean, Black Carribbean Haitian Other, Black Portugese, Black U.S./ African American Native Hawaiian/ Other Pacific Islander Guamanian/Chamorro Hawaiian Other, Pacific Islander Samoan Not Specified/Unknown White Brazilian, White Cape Verdean, White European Middle Eastern Other, White Portuguese, White Two or More Races (not specified) Non-Resident Alien

7 Education: Please check your highest level of education level completed: Less than High School High School Graduate/Equivalent Technical School Some College 2-year College Degree Associates Degree Bachelor s Level Degree Some Graduate School Master s Level Degree Doctorate Post Doctorate DDS DVM JD MD RN LPN 1. High School or G.E.D. 2. Business/Vocational/Trade 3. School of Nursing

8 4. College/University 5. Graduate School 6. Other Signature (checking the checkbox above is equivalent to a handwritten signature)