NEW HIRE FORM
EMPLOYEE NAME
Personnel #
Department Name
Dept. phone
ACTION (IT0000)
Hire Date:
New Hire
Student Hire
Primary Position #
Primary Position Title
Employee: Complete all unshaded areas (please print).
Last name ____________________________________ Name at birth ______________________________
First name _______________________ MI ________
SSN _________________________
Known as (Nick Name)________________________
Gender  Male
Birth date _____/____/______
 Female
PERMANENT HOME ADDRESS (IT0006) (no punctuation)
CURRENT HOME ADDRESS (IT0006) If different than perm.
Spouse’s name ________________________________
_____________________________________________
_____________________________________________
_____________________________________________
City __________________ State______ Zip _________
City __________________ State______ Zip _________
Phone: (
)
E-mail
 I do not wish to have my home address information published in the University directory. (xdir)
EMERGENCY CONTACT (IT0006
Name_____________________________ Phone (_____)____________ E-mail ______________________
WORK ADDRESS (IT0006) (no punctuation or dashes)
Building abbreviation
Room number
State NE
Campus
Zip 68198-
UNMC
Telephone
E-mail
Fax
ORGANIZATIONAL ASSIGNMENT (IT0001) sets up employee relationship to entire University organization
Benefits %:
% for 12mo
% for 9/10mo
Ret/Ancil
Not eligible
PLANNED WORKING TIME (IT0007) sets up employee relationship to his/her current University contract(s)
Employment Percent (FTE)
Leave plan code
Contract length code:
Positive time reporting
BASIC PAY (IT0008) sets up employee relationship to payroll
Wage Type
Amount
hr
mo
Wage Type
Amount
hr
mo
PAID APPOINTMENTS (IT9001) overview of current paid positions for reporting purposes
Start Date
End Date
Position #
Title
Modifier
Budgeted
Annual Salary
FTE %
relative to full time
UNPAID APPOINTMENTS (IT9001) overview of current unpaid positions for reporting purposes
Start Date
End Date
Title
COST DISTRIBUTION (IT9027) matches IT0008, for reporting purposes
Cost Code:
Cost Center / WBS Element
Position #
Wage
Type
Organizational Unit Number
[Distribution: 01-wage]
$ Rate
hourly or monthly
% of Cost
Distribution
Grant funded?
yes
no
Grant funded?
yes
no
TOTAL
Page 1 of 2
= 100%
Revised June 2011
2 PAF
C -Citizen
N -Non-citizen
A –Non-Resident Alien
Attach Form I-9 with photocopies of documentation (required for all new/returning)
RESIDENCE STATUS (I-9) (IT0094)
ADDITIONAL PERSONAL DATA (IT0077)
Ethnicity (select one)
 Hispanic/Latino
 Not Hispanic/Latino
Race (select multiple)
 American Indian/Alaskan Native  Asian  Black or African American
 Native Hawaiian or Other Pacific Islander  White  Unknown
Veteran status
Discharge Date: _________________  Non Veteran
 Special Disabled Veteran
 Vietnam Era Veteran  Other Protected Veteran
 Recently Separated Veteran
 Armed Forces Service Medal Veteran  Disabled Veteran  Unknown
Military status
 Not applicable
Medicare eligible  Yes  No
 Active National Guard
Disability  Yes  No
Date disability determined ____/____/________
DATE SPECIFICATIONS (IT0041) (mm/dd/yyyy)
I-9 Date required (I9)
First Working Day required (40)
University Service Date (UD)
Leave Accrual Date
Health Professions Tracking1 (HP)
Health Professions Contract1 (HC)
(Begin date of the original health professions contract)
(Begin date of the current health professions contract)
Graduate Faculty (GR)
Other
(01)
1
For new faculty hired on Health Professions Appointments HP and HC are the same date.
MONITORING OF TASKS (IT0019) (mm/dd/yyyy)
Probation Expires (01)
HP Contract Expires (07)
Appointment Expires (non HP) (02)
Employment Agreement Expires (EA)
EDUCATION (IT0022) Enter only highest and most recent. (not required for student workers)
Date of graduation ____/____/_____ Institution name (acronym preferred)___________________________________
Certificate/Degree _____________________
Is this the highest possible degree in your field?  Yes  No
(additional degrees, if any)
Date of graduation ____/____/_____ Institution name (acronym preferred)___________________________________
Certificate/Degree _____________________
Is this the highest possible degree in your field?  Yes  No
QUALIFICATIONS (IT0022) ( licenses and certifications, if applicable)
License _____________________________________
Certification ___________________________________
Other _______________________________________
Other ________________________________________
EMPLOYEE SIGNATURE: ___________________________________________________ date____________________________
ADDITIONAL COMMENTS OR EXCEPTIONS:
APPROVAL SIGNATURES:
___________________________________ date____________
___________________________________ date____________
Attachments
Form W-4 (required for all new/returning employees) / Form W-5 (optional)
Form I-9 with photocopies of documentation (required for all new/returning employees)
Bank deposit form
Correspondence and supportive documentation
Page 2 of 2
Revised June 2011