Boise State University Employee Information Form

NAME(Required)

(legal name as it appears on your social security card)

First Last

ADDRESS(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

PHONE(Required)

EMAIL(Required)

GENDER(Required)

Male

Female

DATE OF BIRTH(Required)

XX/XX/XXXX

DEPARTMENT WHERE EMPLOYED

POSITION

STATUS

Faculty

Staff

Student

ESTIMATED WORK BEGIN DATE

YYYY

ARE YOU CURRENTLY, OR HAVE YOU EVER WORKED FOR AN IDAHO STATE AGENCY IN A BENEFIT ELIGIBLE POSITION?

Yes

EMERGENCY CONTACT NAME

EMERGENCY CONTACT PHONE

RELATIONSHIP TO EMPLOYEE

Affirmative Action

Boise State University is an affirmative action employer. In order to assist us in meeting our affirmative action commitments and providing the necessary reports to federal and state agencies, we would appreciate you providing this information. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations. Thank you for your cooperation.

ETHNIC GROUP HISPANIC/LATINO

Check either yes or no. You must be a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race.

Yes

WHAT RACE(S) OR CULTURE(S) DO YOU CONSIDER YOURSELF(Required)

American Indian/Alaskan Native (A person with origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.)

Asian (A person with origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam)

Black/African-American (A person with origins in any of the black racial groups of Africa)

Hispanic (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race)

Native Hawaiian or other Pacific Islander (A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands)

White (A person with origins in any of the original peoples of Europe, North Africa or the Middle East)

Two or more races (not Hispanic or Latino) All persons who identify with more than one of the above races. Mark all that apply above.

Not Specified

Veteran's Status

ARE YOU A US VETERAN?(Required)

Yes

IF YOU ARE A U.S. VETERAN, PLEASE MARK ANY OF THE FOLLOWING BOXES THAT APPLY

Vietnam-Era Veteran – a person who served on active duty for a period of more than 180 days, any part of which occurred between 02/28/1961* and 05/07/1975, and was discharged or released from active duty with other than a dishonorable discharge; or who was discharged or released from active duty for a service connected disability if any of the active duty was performed between 08/05/1964 – 05/07/1975. *Service between 02/28/1961 – 08/14/1964 must have been performed within the Republic of Vietnam.

Special Disabled Veteran – a person who is entitled to compensation under laws administered by the Department of Veteran Affairs for a disability: (a) rated at 30 percent or more, (b) rated at 10 or 20 percent in the case of a veteran who has been determined to have a serious employment handicap, or (c) who has been discharged or released from active duty because of a service-connected disability.

Disabled Veteran – a veteran who served on active duty in the U.S. military, ground, naval or air service who is entitled to compensation under laws administered by the Secretary of Veteran’s Affairs, or was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran – any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.

Armed Forces Service Medal Veteran – a veteran who, while serving on active duty in the U.S. military ground, naval, or air service, participated in a U.S. military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Other Protected Veteran – a 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.

Veteran’s Preference: Eligibility for veteran’s preference is defined in RCW 73.16.010 as honorably discharged soldiers, sailors, and marines who are veterans of any war of the U.S., or of any military campaign for which a campaign ribbon shall have been awarded, and their widow or widowers, shall be preferred for appointment and employment. Age, loss of limb, or other physical impairment, which does not in fact incapacitate, shall not be deemed to disqualify them, provided they possess the capacity necessary to discharge the duties of the position involved: PROVIDED, that spouses of honorably discharged veterans who have a service connected permanent and total disability shall also be preferred for appointment and employment.

ARE YOU A MILITARY VETERAN ELIGIBLE FOR VETERAN’S PREFERENCE?

Yes

ARE YOU A WIDOW/WIDOWER OF A MILITARY VETERAN ELIGIBLE FOR VETERAN’S PREFERENCE?

Yes

ARE YOU A SPOUSE/DOMESTIC PARTNER OF AN ELIGIBLE MILITARY VETERAN WITH A SERVICE CONNECTED PERMANENT AND TOTAL DISABILITY?

Yes

Persons claiming veteran’s preference must provide documentation to verify eligibility such as a DD214 form.

Disability Status

DO YOU HAVE A PERMANENT PHYSICAL, SENSORY, OR MENTAL CONDITION THAT SUBSTANTIALLY LIMITS ANY OF YOUR MAJOR LIFE FUNCTIONS such as working, caring for yourself, walking, doing things with your hands, seeing, hearing, speaking, and learning?(Required)

Yes

Do not wish to answer

Note: If you mark “yes,” you will be identified as an individual who meets the affirmative action criteria for persons with disabilities.

Boise State University Employee Information Form

Affirmative Action

Veteran's Status

Disability Status

Human Resource Services