Employee Information Sheet Template by ace20238

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									                                               PERSONAL INFORMATION FORM
                            (For Officers of Instruction, Officers of Research, & Postdoctoral Fellows)

PART I – TO BE COMPLETED BY EMPLOYEE
Full Name:                                                                                           Gender:         Female   Male
Social Security Number:                                                              Date of Birth: MM/DD/YYYY
Marital Status:      Single      Married        Divorced         Legally Separated     Widowed Marital Status Date: MM/DD/YYYY
Ethnicity:     Asian        Black    East Indian        Hispanic        Native American      White          Other:
USA Citizen?        Yes        No    If No, Country of Citizenship:
Permanent Resident?            Yes        No    If Yes, A#:
Home Address:                                                                          Home Phone:
City, State, Zip:                                                                      Other Phone:
Email:                                                                                        Fax:
Emergency Contact Name:
Relation:                                                                             Contact Phone:
PART II – TO BE COMPLETED BY DIVISION ADMINISTRATION
Status: FT      PT   Eff Date: MM/DD/YYYY    End Date: MM/DD/YYYY
CU Title:
Position Supervisor:
Work Address:
Work Phone:                                                                 Work Fax:
Compensation:        CU Salary            NYPH Salary              CU Stipend         None
Base: $                               AddComp1: $                                      AddComp2: $
FOR CLINICAL FACULTY/FELLOW APPOINTMENTS ONLY
NYPH Title:
Admitting Privileges: NYPH           Full        Limited     /    Allen Pavilion     Yes      No      /    DPO       Yes      No
NYS License:        License          Limited-License              Limited-Permit
License #:                                Profession:                                                     Exp Date: MM/DD/YYYY
DEA #:                                Exp Date: MM/DD/YYYY ECFMG:                    Indefinitely         Limited-Exp Date: MM/DD/YYYY
Infection Control Completion Date: MM/DD/YYYY
Board Certificate Specialty:
Effective Date: MM/DD/YYYY Expiration Date: MM/DD/YYYY
Board Certificate Subspecialty:
Effective Date: MM/DD/YYYY Expiration Date: MM/DD/YYYY
Malpractice Insurance Carrier:
Policy #:                                           Eff Date: MM/DD/YYYY             Exp Date: MM/DD/YYYY
FOR CLINICAL FELLOW APPOINTMENTS ONLY
Program Name:
ACGME?        Yes      No     ACGME #:                                               Fellow Level:                    PGY Level:
FOR FELLOW APPOINTMENTS ONLY
Health Insurance:         Outside Coverage            CU Plan         Student Health
Carrier:     Cigna POS          Cigna Indemnity             Oxford POS        Oxford HMO            HIP       Aetna US Healthcare
Coverage Type:         Individual         Individual & Child         Individual & Spouse        Family
Paid By:     Dept-Full        Dept-Part        Individual   Dept Acct #:                            Dept Partial Amt: $

Part III – FOR DEPARTMENT USE ONLY
Division:
Appointment Type: OOI        OOR     PDF Salary Type: Continuous 1      Annual/Limited 2 Period 3
Affirmative Action Clearance: Full Limited Temp Eff Date: MM/DD/YYYY       End Date: MM/DD/YYYY
Visa Type               Emp Autho Exp Date: MM/DD/YYYY      Practice Plan Participant? Yes     No
JAC:9/03

								
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