Employee Survey

Legal Name

Preferred Name:

Maiden Name:

Street Address:

Phone Number:

Email:

Date of Birth and Birth Country

Sex:

Race:

Do you have any handicaps or disabilities which may interfere with your ability to perform the essential functions of your job with or without reasonable accommodations? Please describe.

Current Marital Status

Spouse's Name , DOB, SSN, and Employer

Is spouse covered on another health insurance plan?

If so, list with what company and the policy number

Any dependents?

If yes, list dependents name, DOB, and SSN

Emergency Contact Info Full Name and Address

Emergency Contact Primary and Alternative Phone Numbers

Emergency Contact Relationship

Courses, Certifications, and Training Classes – Internal & External (Other than degree study)

Military Service

Branch, Discharge Date, Rank, Active/ Inactive

Civic Organization Memberships (List organization/club, dates, and status)