HR USE ONLY
SSC received
Office of Human Resources
Employee Information
PLEASE NOTE: IRS regulation, as well as the Federal Employer’s Tax Guide requires that each employee’s payroll name & number must exactly match their
Social Security card to prevent misdirected social security funds. To verify this, HR must see your original Social Security card and make a copy for your file.
Employee Data
PSU ID Number
Last Name
First Name
Middle Name
Preferred Last Name (if different)
Preferred First Name (if different)
Preferred Middle Name (if different)
Current Address
City
State
Primary Phone Number
PSU Email Address
Zip Code
Emergency Contact Name
Emergency Contact Phone
@pdx.edu
Biographical Data (Please respond to EACH of the 5 data requests)
1. Gender
Male
2. Birth Date
3. Citizenship
Female
Citizen
4. What is your ethnicity?
Hispanic or Latino
5. Select one or more races to indicate
what you consider yourself to be
American Indian or Alaskan Native
Black or African American
White
Resident Alien
NOT Hispanic or Latino
Non-Resident Alien
I choose not to provide this information
Asian
Native Hawaiian or Other Pacific Islander
I choose not to provide this information
Veteran Classification and Self-Identification
I identify as one or more of the classifications of protected veteran listed (please see reverse for definitions and additional information)
Date of Discharge: __________________________________
Disabled veteran
Active wartime or campaign badge veteran
Armed forces service medal veteran
I am not a protected veteran
I am not a veteran
I am a protected veteran, but I choose not to self-identify the classification to which I belong
I choose not to self-identify
Job Information
Start Date
Department Name
Position Title
Are you a Student Employee?
Yes
No
Supervisor Name and Phone Number
If “Yes,” are you a graduate assistant?
Yes
If you are NOT a Student Employee, please provide a copy of your Letter of Offer (if available)
Degree Information (Student Employees do not need to fill out this section)
Highest Degree Earned
Institution, Campus, City, State
Grad. Date (Month/Year)
Oregon Public Employees Retirement System (PERS) Status
Have you ever been an Oregon PERS
member?
Yes
No
Are you currently employed by another
Oregon PERS employer?
Employee Signature and Date
Signature
Veteran Classification and Self-Identification
Rev 9-25-15
Date
Yes
No
No
This employer is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as
amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take
affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty
wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows:




A “disabled veteran” is one of the following:
o A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who, but for the
receipt of military retired pay, would be entitled to compensation) under laws administered by the Secretary of
Veterans Affairs; or
o A person who was discharged or released from active duty because of a service-connected disability
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such
veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military,
ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been
authorized under the laws administered by the Department of Defense.
An “Armed Forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military,
ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal
was awarded pursuant to Executive Order 12985.
Protected veterans may have additional rights under USERRA-the Uniformed Services Employment and Reemployment Rights
Act. In particular, if you were absent from employment in order to perform service in the uniformed service, you may be
entitled to be reemployed by your employer in the position you would have obtained with reasonable certainty if not for the
absence due to service. For more information, call the U.S. Department of Labor’s Veterans Employment and Training Service
(VETS), toll-free, at 1-866-4-USA-DOL (1-866-487-2365).
Reasonable Accommodation
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if
you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation
include making a change to the application process or work procedures, providing documents in an alternate format, using a sign
language interpreter, or using specialized equipment.
Where can I find more information?
For more information about the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office
of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp
Please contact PSU HR at 503-725-4926 if you need to request an accommodation.
If you have any questions regarding Affirmative Action reporting requirements, please contact the Office of Equity and
Compliance at 503-725-5919 or via email at diversity@pdx.edu
HR USE ONLY
Unclassified
Teaching/Research .5+ FTE (UA, UB)
Teaching/Research <.5 FTE (UC, UD)
Non-Teaching .5 + FTE (UE, UF)
Non-Teaching <.5 (UG, UH)
Unclassified Teaching/Research
Hourly-All Appointments (UT)
Police Officer (GI)
Copy to Benefits if PERS
response is “yes” (from page 1)
Rev 9-25-15
Classified
Student
Full-Time Salaried (CA)
Part-Time Salaried (CB)
Full-Time Hourly (CD)
Part-Time Hourly (CE)
IATSE Hourly <1 FTE (GJ)
Student Employee (XA)
Graduate Assistant (XB)
Graduate Administrative Assistant (XC)
Temporary
Temporary Employee (TS)
Wage Appointment Salaried (UV)
Wage Appointment Hourly (UW)
I have checked
the NOF List
Terminal Degree?
Yes
Input by/Date
No