State of Kansas Employee Payroll - PDF

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					         KUHRPAY(8/10)                         University of Kansas Employee Data Sheet                                         www.payroll.ku.edu

        Please type or print legibly. Information is keyed directly into the Human Resource/Payroll System from this form.
                                             Enter name as it is printed on your social security card.
Last/Family                                  Suffix   First                           Middle                          Social Security Number


Preferred Name                                                                                  Former
(Directory Use)                                                                                 Names
Home (W2)
Address
                                Street                             City                        County        State        Zip              Phone
                                                                                              (KS/MO)
Mailing (if
different from
Home)                           Street                             City                        County        State        Zip              Phone
                                                                                              (KS/MO)
                                           For those with options listed, please circle the correct value.
                  1-Year         2-Years                                  3-Years   4-Years                                        High School Graduate o
Highest                                       2-Year College Degree                             Bachelor's Degree      Doctorate
                  College        College                                  College   College                                              Equivalent
Education
Level
                   Less than High School Graduate           Master's Degree            Post Doctorate       Some Graduate School      Technical School


Gender (M/F)                        E-mail Address                                                        Campus Work Phone
                                                          Juniper
Primary Campus Work                        Edward                     KGS Well                                         Capitol       KUMC
                                   KU                    Gardens                               KLETC        Talent                                  KUMC
                                           Campus,                      Library   Parsons,                             Center,       Kansas
Location. Please circle or     Lawrence,KS               Complex,                             Yoder,KS      Search,                                Wichita,
                                           OP, KS                     Wichita, KS KS (LB)                            Topeka, KS      City,KS
write in the City/State.          (DG)                    KC,KS                                 (RN)      KC,KS (WY)                               KS (SG)
                                            (JO)                         (SG)                                           (SN)          (WY)
                                                           (WY)

         Other (City/State):

Non-Tax Marital Status optional               Married     Single

Birth Date (MM/DD/YY)                                                     KU Student ID # (if student employee)

If Non U.S. Citizen - indicate Birth Country                                                       and Birth City

Citizenship Status               Alien Permanent           Alien Temporary                Native                     Naturalized

                                                A person of Cuban, Mexican, Puerto Rican, South or Central               YES, Hispanic or Latino
Are you Hispanic or Latino?
                                               American, or other Spanish culture or origin regardless of race.
                                                                                                                         NO, Not Hispanic or Latino
In addition, choose one or more of the following racial categories to describe yourself: (circle)


                                                             Asian:                                        Native Hawaiian or
                                             A person having origins in any of                                Other Pacific                White:
 American Indian or Alaska Native:                                               Black or African
                                                the original peoples of the Far                                  Islander:            A person having
 A person having origins in any of the                                               American:
                                                 East, Southeast Asia, or the                                A person having        origins in any of the
  original peoples of North and South                                             A person having
                                               Indian subcontinent, including,                             origins in any of the     original peoples of
 America (including Central America),                                           origins in any of the
                                              for example, Cambodia, China,                                 original peoples of     Europe, the Middle
 and who maintains tribal affiliation or                                        black racial groups
                                               India, Japan, Korea, Malaysia,                                 Hawaii, Guam,            East, or North
        community attachment.                                                         of Africa.
                                             Pakistan, the Philippine Islands,                               Samoa, or other               Africa.
                                                   Thailand, and Vietnam.                                     Pacific Islands.


The State of Kansas uses a one-question format for reporting purposes. Please indicate your primary race: (circle)
American Indian or Alaska Asian/Pacific Islander           Black or African
                                                                                       Hispanic (3)       White-not Hispanic (1)
       Native (5)                 (4)                       American (2)

                                                               Please see the back.



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         KUHRPAY(8/10)                    University of Kansas Employee Data Sheet                                www.payroll.ku.edu


Military Status and Recently Separated Veteran
(see Invitation to Self-Identify Disabled and/or Veteran Status for descriptions). optional

Disabled Veterans, please fill out the additional form Disclosure Form for Persons with Disabilities

               Vietnam-    Other        Vietnam Era Veteran                     If Recently Separated Veteran -
No Military                                                 Veteran/Military
               Era Veteran Protected    & Other Protected                       please indicate the date of
Service 2                                                   Status Not Listed A
               3           Veteran 4    Veteran 9                               discharge or release :

If you have served on active duty and received an Armed Forces Service Medal, please circle Yes (if not, circle
                                                                                                                         Yes            No
No). (See the Invitation to Self-Identify Disabled and/or Veteran Status for a description.)

Professional Education:
                  Date
Degree         (MM/DD/YY)                Major                                  School                             Country/State




Current or Past Employment at the University of Kansas or any other State of Kansas Agency               (Payroll-copy HREO if data.)


Agency/Division Name                                                                             Dates

Agency/Division Name                                                                             Dates


Are you a KPERS retiree? (circle)       Yes   No        If yes, from what employer did you retire?




Employee Signature:                                                                              Date:




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