l!J
Ursinus
College
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STAFF CENSUS SHEET
Last Name: ________________________ Department: _________________________
First Name: ________________________ Job Title: ___________________________
Street Address: ________________________________________________________
State: ______ Zip Code: _________ Home Phone: ________________ Cell Phone: __________________
nternal Use Only
Reports to:
___________________
Job Class (EEOC):
___________________
SOC Code:
___________________
Voluntary Self – Identification Information
Completion of this information is voluntary and is not a requirement. This information will be kept
confidential
Gender: Male
Female
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Two or more races
Race Unknown
Ethnicity: Hispanic or Latino
Not Hispanic or Latino Race:
Residency Status: A citizen of the United States
A noncitizen of the United States
A lawful permanent resident
An alien authorized to work in the United States until (date) ____/_____/_______
Veteran Status: I identify as one or more classification of protected veteran
Disabled Veteran
Recently Separated Veteran (Discharge Date ____/_____/________)
Active Duty Wartime or Campaign Badge Veteran
Armed Forces Service Medal Veteran
I am not a protected veteran
I decline to self-identify
Emergency Contact Information:
Name: ____________________________________ Relationship: ___________________________________
Contact Phone: ______________________________ Contact Email: __________________________________
Contact Address: __________________________________________________________________________________
Signature: _____________________________________ Date: ____/____/_______
click to sign
signature
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