ACTION (IT0000) New Hire - Rehired Student Hire - Rehired

1 PAF

EMPLOYEE NAME / Personnel #
Department Name / Org Unit No. / Dept. phone

REQ/RAF #

/

Reports toPosition No.

/

Leave Approver Position No.

ACTION (IT0000) New Hire - Rehired Student Hire - Rehired

Hire Date:

/

Primary Position #

/

Primary Position Title

/

Emp Subgroup:

Employee Group: Nonresident alien?  Yes  No  Federal Employee

Employee: Complete all unshaded areas (please print).

Last name ______Name at birth ______

First name ______MI ______Known as (Nick Name)______
SSN ______Birth date_____/____/______Gender  Male Female

Nationality ______
ORGANIZATIONAL ASSIGNMENT (IT0001) sets up employee relationship to entire University organization
Benefits %: % for 12mo% for 9/10mo Ret/Ancil Not eligible
PERMANENT HOME ADDRESS (IT0006) (no punctuation)
Spouse’s name ______
______
City ______State______Zip ______/ CURRENT HOME ADDRESS (IT0006) If different than perm.
______
______
City ______State______Zip ______
EMAIL ______PHONE (______)______
WORKADDRESS (IT0006) (no punctuation or dashes)
Building abbreviation / Room number / Campus UNMC
State NE / Zip 68198- / Telephone
Fax / E-mail

EMERGENCY CONTACT (IT0006)

Name______Phone (_____)______E-mail ______

PLANNED WORKING TIME (IT0007) sets up employee relationship to his/her current University contract(s)
Employment Percent (FTE) Leave plan code Contract length code: Positive time reporting
BASIC PAY (IT0008) sets up employee relationship to payroll
Wage Type Amount hr mo / Wage Type Amount hr mo
COST DISTRIBUTION (IT9027) matches IT0008, for reporting purposes [Distribution: 01-wage]
Cost Code: / Cost Center / WBS Element / Position # / Wage Type / $ Rate
hourly or monthly / % of Cost Distribution
Grant funded?
yes no
Grant funded?
yes no
TOTAL / = 100%
PAID APPOINTMENTS (IT9001)
Start Date / End Date / Position # / Title / Title Modifier / Annual Salary / FTE %
relative to full time
UNPAID APPOINTMENTS (IT9001)
Start Date / End Date / Title / Organizational Unit Number

RESIDENCE STATUS (I-9) (IT0094) C -Citizen N -Non-citizen A –Non-Resident Alien

Attach Form I-9 with photocopies of documentation (required for all new/returning)

ADDITIONAL PERSONAL DATA (IT0077)

Ethnicity (select one)  Hispanic/Latino (E1)  Not Hispanic/Latino (E2)

Race (select all applicable) American Indian/Alaskan Native (R1)  Asian (R2)  Black or African American (R3)

 Native Hawaiian or Other Pacific Islander (R4)  White (R5)  Unknown (R6)

Veteran statusDischarge Date: ______ Non Veteran (V1)  Special Disabled Veteran (V2)

 Vietnam Era Veteran (V3)  Other Protected Veteran (V4)  Recently Separated Veteran (V5)

Armed Forces Service Medal Veteran (V6)  Disabled Veteran (V7)  Unknown (V8)

Military statusNot applicable  Active National Guard

Medicare eligible  Yes  NoDisability  Yes  No Date disability determined ____/____/______

DATE SPECIFICATIONS (IT0041) (mm/dd/yyyy)
I-9 Date required (I9) / First Working Day required (40)
University Service Date (UD) / Leave Accrual Date (01)
Health Professions Tracking1(HP)
(Begin date of the original health professions contract) / Health Professions Contract1 (HC)
(Begin date of the current health professions contract)
Graduate Faculty (GR) / Other

1For new faculty hiredon Health Professions Appointments HP and HC are the same date.

MONITORING OF TASKS (IT0019)(mm/dd/yyyy)
Probation Expires (01) / HP Contract Expires (07)
Appointment Expires (non HP) (02) / Employment Agreement Expires (EA)

EDUCATION (IT0022)Enter only highest and most recent.(not required for student workers)

Date of graduation ____/____/_____ Institution name (acronym preferred)______

Degree ______(e.g. BS, MA, MSN, MD, PhD, DDS, etc.) Is this the highest possible degree in your field?  Yes  No

(additional degrees, if any)

Date of graduation ____/____/_____ Institution name (acronym preferred)______

Degree ______(e.g. BS, MA, MSN, MD, PhD, DDS, etc.) Is this the highest possible degree in your field?  Yes  No

QUALIFICATIONS (IT0022) ( licenses and certifications, if applicable)
License ______/ Certification ______
Other ______/ Other ______

EMPLOYEE SIGNATURE: ______date______

ADDITIONAL COMMENTS OR EXCEPTIONS:

APPROVAL SIGNATURES:

______date______date______

Attachments

Form W-4 (required for all new/returning employees) / Form W-5 (optional)

Form I-9 with photocopies of documentation (required for all new/returning employees)

Bank deposit form

Correspondence and supportive documentation

Page 1 of 2Revised July 2018