General Employee Information Form - Texas

Employee Information Form
Revised 2/2015
Instructions:
You can update this information online using the Employee Information System at utdirect.utexas.edu/pnbiog/index.WBX. If you
do not have access to the online system, print a copy of this form, complete it, and return it to your supervisor or the HR Contact in
your department. DO NOT RETURN THIS FORM TO HUMAN RESOURCES.
First name Middle name Last name
UT EID E-mail Home phone
Street address
City State Zip code
Office Location
Primary location
Building Office phoneRoom
Secondary location
Building Office phoneRoom
Pager Fax Campus mail code
Emergency Contacts
Primary contact
Name
Phone 1 Phone 2
Relationship
Secondary contact
Name
Phone 1 Phone 2
Relationship
Gender
Male Female
Information Release -- Do Not Release My...
(Mark all that apply)
Social Security Number
Family Information
Home Address(es)
Home Phone Number(s)
Emergency Contact
Education
Indicate highest level of education achieved.
Less than high school
High school diploma/GED
Associate’s degree
Certificate of completion
Bachelor’s degree
Master’s degree
Professional degree
(LLB, JD, ThD, PharmD)
Medical degree (MD, DVM, DDS)
Doctorate (PhD,EdD)
Highest degree abbreviation
Total years of teaching experience
Total years of teaching experience at UT Austin
Signature of employee
Date form signed
Year degree completed
Teaching Experience
Please indicate the years of HIGHER education teaching experience you have
(excluding TA experience)
Former Foster Children
Are you less than the age of 25 and an orphan under permanent managing
conservatorship of the Department of Family and Protective Services (DFPS)?
Yes No
EID
Ethnicity
Are you Hispanic?
Yes No
American Indian/Alaskan native
Asian
Black
Native Hawaiian/Pacific Islander
White
Race (check all that apply)
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