Medical Residents Bio-Demographic Form The George Washington University is required by law to maintain records of your employment. The information requested below will become part of your employee record and will be confidentially maintained. You are asked to furnish all the information requested below. If any item is not applicable to you, please write N/A in the appropriate space. Information below must match legal documentation (i.e. I-9 or Social Security Card). Name First Middle? Last Social Security Number Date of Birth Phone Number Email Position Title Date of Hire Gender Male Female Marital Status Single Married Divorced Widowed Have you ever applied to GW as a student? Yes No Have you been affiliated with GW before? Yes No (e.g. as a student, faculty or staff member, affiliate) GWID (If known) Are you currently a GW student? Yes No Other name you may have had while previously affiliated with GW Demographic Data Employment Eligibility Status US Citizen Non-Citizen National of the US Lawful Permanent Resident Alien with temporary authorization Colleges and universities are asked by many, including the federal government, accrediting associations, college guides, and our own college/university communities, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask that you answer the following two questions on ethnicity and race. 1. Do you consider yourself to be Hispanic or Latino? (Persons of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race) Yes No 2. In addition, you may select one or more of the following racial categories to describe yourself: White Black or African American Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Veterans' Status Non-Veteran Other Protected Veteran Vietnam Veteran Only Both Vietnam/Other Elig. Vet Armed Forces Service Medal Veteran If both Vietnam/other eligible veteran, date of separation: If both Vietnam/other eligible veteran, date of separation:: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec If both Vietnam/other eligible veteran, date of separation:: Day Day12345678910111213141516171819202122232425262728293031 If both Vietnam/other eligible veteran, date of separation:: Year Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Disability Status None Visual Hearing Mobility Other… If other disability status, please list If you need a reasonable accommodation, contact the EEO Department to make your request. Are any relatives or members of your household currently employed with GW? Yes No If yes, please list: Name Department Relationship to you Name 2 Department 2 Relationship to you 2 Address and Emergency Contact Information Campus Address (Address of primary office, if known) Name of your department Campus Street Address Campus Address City Campus Address State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Campus Address Zip Code Campus Phone Number Home Address Home Address Home Street Address Home Address 2 City/Town Home State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Home ZIP/Postal Code Home Phone Home Email Address Emergency Contact Information Emergency Contact Name Relationship to You Contact Address Contact Street Address Contact Address 2 Contact City/Town Contact State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Contact Phone Number Please report any changes to the information listed above to Human Resource Management and Development. 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