EMPLOYEE NAME
Personnel #
Department Name
Dept. phone
New Hire Form
Employee: Complete all unshaded areas (please print).
ACTIONS From
(MM/DD/YYYY)
DESCRIPTION OF ACTION
New Hire REQ/RAF #
ACTION (IT0000)
Primary Position #
Student Hire
Volunteer Hire
Primary Position Title
Employee Group --Non-resident alien?
yes
no
Federal Employee
PERSONAL DATA (IT0002)
Last name _________________________________
Name at birth ____________________
First name _________________________________
Middle initial
Known as (Nick Name) ___________________________
SSN ____________________________
Birth date
____/___/______
Gender
__________ (no period)
 Male
 Female
Nationality ________________________________________________________________________
PERMANENT HOME ADDRESS (IT0006)
(no punctuation or dashes)
Spouse’s name (if applicable)________________________________________________________
1 ______________________________________________________________________________
2 ______________________________________________________________________________
City _____________________________________
State ______ Zip ____________ - _____
Telephone (________) _______________________
E-mail _____________________________
CURRENT HOME ADDRESS (IT0006)
(no punctuation or dashes)
c/o_____________________________________________________________________________
1 ______________________________________________________________________________
2 ______________________________________________________________________________
City _____________________________________
State ______ Zip ____________ - _____
Telephone (________) _______________________
E-mail _____________________________
EMERGENCY CONTACT (IT0006)
(no punctuation or dashes)
Name___________________________________________________________________________
Telephone (________) _______________________
E-mail _____________________________
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Revised Feb 2017
2 PAF
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)
Positive time reporting
Employment Percent (FTE)
Contract length code:
Leave plan code
BASIC PAY (IT0008) sets up employee relationship to payroll
Wage Type
Amount
hr
mo
Wage Type
Amount
hr
mo
Wage Type
Amount
hr
mo
Wage Type
Amount
hr
mo
COST DISTRIBUTION (IT9027) matches IT0008, for reporting purposes
Cost Code:
Cost Center / WBS Element
Position #
Wage
Type
[Distribution: 01-wage]
$ Rate
% of Cost
hourly or monthly
Distribution
Grant funded?
yes
no
Grant funded?
yes
no
Grant funded?
yes
no
Grant funded?
yes
no
TOTAL
= 100%
PAID APPOINTMENTS (IT9001)
Start Date
End Date
Position
#
Title
Title
Modifier
Annual
Salary
FTE %
relative to full
time
UNPAID APPOINTMENTS (IT9001)
Start Date
End Date
BANK DETAILS (IT0009)
Title
Attach Bank deposit form Change DEPT to HOME
TAX WITHHOLDING W4 / W5 (IT0210)
Organizational Unit Number
TAX AREA (IT0207): NE
Attach Form W-4 (required for all new/returning) / Form W-5 (optional)
Completed by Payroll
RESIDENCE STATUS (I-9) (IT0094)
C -Citizen
N -Non-citizen
Attach Form I-9 with photocopies of documentation (required for all new/returning)
A –Non-Resident Alien
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Revised June 2011
3 PAF
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 __________________________
1For
(01)
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 3 of 3
Revised June 2011