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).

(e.g. as a student, faculty or staff member, affiliate)

Other name you may have had while previously affiliated with GW

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.

Black or African American

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

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 other disability status, please list

If you need a reasonable accommodation, contact the EEO Department to make your request.

If yes, please list:

Relationship to you 2

Campus Address (Address of primary office, if known)

Name of your department

Campus Street Address

Campus Address State

Campus Address Zip Code

Home ZIP/Postal Code

Emergency Contact Name

Contact Street Address

Contact State/Province

Contact Phone Number

Please report any changes to the information listed above to Human Resource Management and Development.

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Demographic Data

Address and Emergency Contact Information

Emergency Contact Information

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