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).

Gender *
Marital Status
Have you ever applied to GW as a student? *
Have you been affiliated with GW before? *
(e.g. as a student, faculty or staff member, affiliate)
Are you currently a GW student? *

Demographic Data

Employment Eligibility Status *

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)
2. In addition, you may select one or more of the following racial categories to describe yourself:
Veterans' Status
If both Vietnam/other eligible veteran, date of separation:
Disability Status

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?

If yes, please list:

Address and Emergency Contact Information

Campus Address
(Address of primary office, if known)
Campus Address State
Home Address
Home State *
Emergency Contact Information
Contact State
Please report any changes to the information listed above to Human Resource Management and Development.