1 PAF

EMPLOYEE NAME / Personnel #
Department Name / Dept. phone

New Hire Form

Employee: Complete all unshaded areas (please print).

ACTIONS From (MM/DD/YYYY)

DESCRIPTION OF ACTION New Hire Student Hire CrHrs Volunteer Hire

ACTION (IT0000)

Primary Position #

/

Primary Position Title

Employee Group --Non-resident alien? yes no Federal Employee

PERSONAL DATA (IT0002)

Last name______Name at birth ______

First name______Middle initial______(no period)

Known as (Nick Name)______SSN______Birth date ______/______/______Gender  Male  Female

ORGANIZATIONAL ASSIGNMENT (IT0001) sets up employee relationship to entire University organization

Benefits %: % for 12mo% for 9/10mo Ret/Ancil Not eligible

CURRENT POSITIONS AT THE UNIVERSITY

Position Number / Position Title / Staffing Percent
This Position
2
3
4
5
6
TOTAL / = 100 %

PERMANENT HOME ADDRESS (IT0006) (no punctuation or dashes)

Spouse’s name (if applicable)______

1 ______

2 ______

City ______State ______Zip ______- _____

Telephone (______) ______E-mail ______

 I do not wish to have my home address information published in the University directory. (xdir)

CURRENT HOME ADDRESS (IT0006) (no punctuation or dashes)

c/o______

1 ______

2 ______

City ______State ______Zip ______- _____

Telephone (______) ______E-mail ______

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WORKADDRESS (IT0006) (no punctuation or dashes)
Building abbreviation / Room number / Campus UNMC
State NE / Zip 68198- / Telephone
Fax / E-mail

EMERGENCY CONTACT (IT0006) (no punctuation or dashes)

Name______

Telephone (______) ______E-mail ______

PLANNED WORKING TIME (IT0007) sets up employee relationship to his/her current University contract(s)

Positive time reporting Employment Percent (FTE) Contract length code: Leave plan code

BASIC PAY (IT0008) sets up employee relationship to payroll

Wage Type Amount hr mo / Wage Type Amount hr mo
Wage Type Amount hr mo / Wage Type Amount hr mo

COST DISTRIBUTION (IT9027) matches IT0008, for reporting purposes [Distribution: 01-wage]

Cost Code: / CostCenter / WBS Element / Position # / Wage Type / $ Rate
hourly or monthly / % of Cost Distribution
Grant funded?
yes no
Grant funded?
yes no
Grant funded?
yes no
Grant funded?
yes no
TOTAL / = 100%

PAID APPOINTMENTS (IT9001) overview of current paid positions for reporting purposes

Start Date / End Date / Position # / Title Modifier / Budgeted
Annual Salary / FTE %
relative to full time

UNPAID APPOINTMENTS (IT9001) overview of current unpaid positions for reporting purposes

Start Date / End Date / Title / Organizational Unit Number

BANK DETAILS (IT0009) Attach Bank deposit form

Change DEPT to HOME

TAX AREA (IT0207): NE

TAX WITHHOLDING W4 / W5 (IT0210) Attach Form W-4 (required for all new/returning) / Form W-5 (optional)

Completed by Payroll

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)

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ADDITIONAL PERSONAL DATA (IT0077)

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

Race (select multiple) American Indian/Alaskan Native  Asian  Black or African American

 Native Hawaiian or Other Pacific Islander  White  Unknown

Veteran statusDischarge Date: ______ Non Veteran  Special Disabled Veteran

 Vietnam Era Veteran  Other Protected Veteran  Recently Separated Veteran

 Armed Forces Service Medal Veteran  Disabled Veteran  Unknown

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 hired on 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)______

Certificate/Degree ______Is this the highest possible degree in your field?  Yes  No

------(additional degrees, if any)

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

Certificate/Degree ______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______

AttachmentsAttachments

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 3Revised June 2011