HR Employee Information Form

* = required field

Some content may be updated based on selection

Academic Affairs
7000 Mercy Road
Omaha, Neb. 68106
Phone: 402-399-2693
Email: academicaffairs@CSM.edu

EMPLOYEE INFORMATION AND EMERGENCY CONTACT FORM

Today's Date:

GENERAL INFORMATION

First Name:

Middle Name:

Last Name:

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Other:

Gender:

Date of Birth:

Non-CSM Email:

OTHER INFORMATION

Former Name(s) Used:

Marital Status:

Highest degree completed:

Religion (optional):

EMERGENCY CONTACT INFORMATION

Faculty and staff are asked to have at least two emergency contacts. We encourage at least one contact who does not live in the same home, e.g. a spouse and a neighbor or a spouse and an adult child living away from home. We also encourage emergency contacts be those who live in the greater Omaha area and thus could easily assist in an emergency.

Name of Contact #1:

Phone Number(s):

Relationship:

Name of Contact #2:

Phone Number(s):

Relationship:

RACE & ETHNICITY GOVERNMENT REPORTING (OPTIONAL)

Do you consider yourself to be Hispanic/Latino –a person of Cuban, Mexican, Puerto Rican, South or Central America, or other Spanish culture or origin, regardless of race?

In addition, select one or more of the following racial categories to describe yourself:

American Indian or Alaska Native – a person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.

Asian – a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American – a person having origins in any of the black racial groups of Africa.

Native Hawaiian or Pacific Islander – a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White – a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

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