Data Collection Documents List

With the implementation of the new Human Resource Information System (HRIS), it is mandatory that every employee complete the following form so that we will have the entire record for each employee. When you print letters and numbers make sure they are legible. Be sure to print only one character per box, keeping the character's lines completely inside the box. This form must be completed in BLACK INK ONLY (do not use pencil or blue pen). Start at the far left of each set of boxes. Leave any blanks at the end. When selecting a box, please use an X. We cannot accept a copy, therefore, extra originals are being provided. Please do not fold or staple the data collection form. If you have any problems or questions, please contact Lisa Collins at 558-3950 extension 225, or Teresa Morgan at extension 221. You can also send your questions via e-mail to

Box 1: Enter your social security number. You will notice that the dashes have been inserted already. The social security number MUST be on both pages of the form.

Box 2: Enter your birth date as follows: two digit month, two digit day, and four digit year. An example would be January 7, 1934 would be listed as 01 - 07 - 1934.

Box 3: Organization number. This field has been completed.

Box 4: Enter your office phone number, including area code and extension, if applicable. If you don't have an extension, leave this field blank.

Box 5: Enter your home phone number, including area code.

Box 6: Enter your last name.

Box 7: Enter your first name.

Box 8: Enter your middle initial, if applicable.

Box 9: Enter your suffix (Sr., Jr., II, III, etc.). If not applicable, leave blank.

Box 10: Mark the appropriate box. (Only one box.)

Box 11: Enter Visa expiration, if applicable, as follows: two digit month, two digit day, and four digit year. An example would be January 5, 1934 would be listed as 01 /05/ 1934.

Work Address #1 - Physical Location. This is the address where you are actually located.

Box 12: Enter the Building Number or code. If not applicable, leave blank.

Box 13: Enter the Room Number. If not applicable, leave blank.

If you entered a Building # or code in Box 12 skip boxes 14 through 25 and proceed to Box #26

Box 14: Enter the two digit work county code

Box 15: Enter street number and name where you are physically located.

Box 16: Enter the city for your physical work address.

Box 17: State for physical work address. This field has been completed.

Box 18: Enter the zip code for your physical work address. Include last four digits if known.

Work Address #2 - Mailing Address. This is the address where you receive mail. If your Work Address is the same as your Physical Address, leave boxes 19 through 25 blank and proceed to Box #26.

Box 19: Enter the Building Number. If not applicable, leave blank

Box 20: Enter the Room Number. If not applicable, leave blank.

Box 21: Enter the two digit work county code.

Box 22: Enter street number and name for mailing address.

Box 23: Enter the city for your mailing address

Box 24: State for mailing address. This field has been completed.

Box 25: Enter the zip code for your mailing address. Include last four digits if known

Box 26: Required for males ages 18-25 ONLY. All others go to box 27. Mark yes if you have registered with Selective Service, no if you have not registered with Selective Service.

Box 27: Mark appropriate box.

Box 28: Mark the appropriate box. (Only one box.) Choose from the following

• Manager of a Department would be a Cabinet Secretary

• Manager of a Division would be a Agency Head, Director, Commissioner or Bureau Chief.

• Manager of Managers would be someone who supervises other Supervisors

• Supervisor of Employees would be someone who has authority to hire employees, discipline employees, assign merit increases, are the 1^st step in the grievance process, and completes employee performance evaluations.

• Not a Supervisor.

Box 29: Mark the appropriate box.

Box 30: Mark the appropriate box.

Starting with the most appropriate skill/trade, complete numbers 31 through 42. If more than two apply, this additional information will be collected at a later date. If no vocational/technical experience, go to number 43.

Box 31: Using the list provided, find the four digit school code for the Vocational/Technical school attended after High School. Enter the number into the boxes.

Box 32: Using the list provided, find the two digit code for the state where the school is located and enter.

Box 33: Using the list provided, find the four digit code for the field of study and enter.

Box 34: Using the list provided, find the two digit certificate code and enter.

Box 35: Enter the number of hours completed.

Box 36: Enter the date certificate was attained as follows: two digit month, and four digit year. An example would be January, 1934 would be listed as 01 / 1934.

Box 37 through 42: Use this set of boxes if more than one certificate is attained or in progress.

Starting with the highest degree attained (Ph.D., M.S., M.A., M.B.A., B.S., B.A., A.S.), complete numbers 43 through 60. If hours were acquired from more than one school and transferred to obtain a degree, only list the college where the degree was attained. If more than three degrees apply, this additional information will be collected at a later date. If no college or university experience, go to box 61.

Box 43: Using the list provided, find the three or four digit college or university code and enter them in the boxes.

Box 44: Using the list provided, find the two digit code for the state where the school is located and enter.

Box 45: Using the list provided, find the four digit code for the major and enter.

Box 46: Using the list provided, find the two digit degree code and enter.

Box 47: Enter the number of hours completed. (Not required if degree has been attained.)

Box 48: Enter the date degree was attained as follows: two digit month, and four digit year. An example would be January, 1934 would be listed as 01 / 1934. If degree is not attained, leave blank.

Box 49 through 60: Use this set of boxes if more than one degree is necessary.

Starting with any mandatory professional licenses, registrations or certificates, complete numbers 61 through 72. If more than two apply, this additional information will be collected at a later date.

Box 61: Using the list provided, find the three or four digit type code and enter.

Box 62: Enter the license number.

Box 63: Using the list provided, find the two digit code for the state where the license was issued.

Box 64: Enter the two digit code for the level, if applicable and enter. If no level is appropriate leave blank.

Box 65: Enter the date license was issued as follows: two digit month, two digit day, and four digit year. An example would be January 5, 1934 would be listed as 01 /05/ 1934.

Box 66: Enter the date license will expire as follows: two digit month, two digit day, and four digit year. An example would be January 5, 1934 would be listed as 01 /05/ 1934.

Box 67 through 72: Use this set of boxes if you have more than one license.