Fillable UW Employee Self-Identification and W-4 Withholding Forms (University of Wisconsin - Parkside)

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UW Employee Self-Identification and W-4 Withholding Forms (University of Wisconsin - Parkside)

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University of Wisconsin Service Center Human Resource System
H322.20140324
UW Employee Self-Identification and W-4 Withholding Forms
The University is required to collect data on race and ethnicity from its employees to comply with federal record keeping
and reporting requirements. The information obtained will be kept confidential and will be used for summary federal
reporting purposes and to support institutional affirmative action efforts. Providing this information is voluntary.
The University also needs your W-4 Withholding Form so you have the appropriate taxes taken.
Last Name:
First Name:
Middle Initial:
Empl ID: (if known)
National ID Type:
Social Security Number Individual Tax ID Number
SSN or ITIN:
Date of Birth:
Sex:
Routing Instructions: Submit to your local HR/Payroll Office. (If at UW-Madison, submit to 21 North Park Street, Suite
5101.)
Ethnicity and Heritage Code
Ethnicity is considered Hispanic/Latino if a person is of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race.
Is your ethnicity Hispanic/Latino?
Yes
No
Please identify yourself as one or more of the following races:
Black or African American
A person having origins in any of the black racial groups of Africa
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.
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.
White
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Native Hawaiian or other Pacific Islander
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Signature: Date:
_____________________________________________________________________ _______________________
For Office Use Only | Empl ID: ___________________ Empl Rcd#: _______________
__________________________ __________________
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities
i
To help us measure how well we are doing, we are asking you to tell us if you
have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disabilities include, but ar
e not limited to:
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular
dystrophy
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or
partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental
retardation)
Please check one of the boxes below:
☐
YES, I HAVE A DISABILITY (or previously had a disability)
☐
NO, I DON’T HAVE A DISABILITY
☐
I DON’T WISH TO ANSWER
Your
Name
Tod
ay’s Date
i
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
P
lease 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.
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employ
ment 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.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.
University of Wisconsin Service Center Human Resource System
H322.20140324
Veteran Self-Identification
Last Name: First Name: Middle Initial:
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.
As a Government contractor subject to VEVRAA, we are required to submit a report to the United States Department of Labor each
year identifying the number of our employees belonging to each specified “protected veteran” category. If you believe you belong to any
of the categories of protected veterans listed above, please indicate by checking the appropriate box below.
I belong to the following classifications of protected veterans (choose all that apply):
Disabled veteran
Recently separated veteran
Active wartime or campaign badge veteran
Armed forces service medal veteran
I am a protected veteran, but I choose not to self-identify the classifications to which I belong.
I am a veteran, but not a protected veteran.
I am not a veteran.
If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you
to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way
the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in
making reasonable accommodations for your disability.
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information
provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as
amended.
The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions
on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be
informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government
officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans
with Disabilities Act, may be informed.
Signature: Date:
___________________________________________________________________________ _______________________
Routing Instructions: Submit to your local HR/Payroll office. If at UW-Madison, submit to 21 N. Park Street, Suite 5101.
For Office Use Only | Empl ID: ___________________ Empl Rcd#: _______________
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UW Employee Self-Identification and W-4 Withholding Forms (University of Wisconsin - Parkside)

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Completed 31 August 2020

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