Employee Demographic Data Form
Instructions:
1. New Employees Complete Parts 1, 2, 3, 5, 6, 7, 8 & 10 and return to your department.
2. Current Employees Complete Part 1 & 10, then only those items that need to be updated or changed.
3. Forward form to your department for processing.
Part 1 Identification/Status
New Employee Re-Hire Change/Update Data
Employee’s Name (Last Name, First Name, MI) as they appear on your Social Security Card. Prefix: Suffix:
For Name Changes use form HRSF0046 (Request to Change Primary/Legal Name): Mr. Dr. II Sr.
Ms. Miss III
Mrs. Jr.
SBID #: Social Security Number:
Part 2 Employee Contact Information
Permanent Address: City: County:
State: Zip: Country: Phone Number:
Mailing Address (if different): City: County:
State: Zip: Country:
Phone: Cell Phone: Fax:
Email:
Part 3 Affirmative Action Information
(New York State Policy Permits Eliciting This Information Following Appointment.)
Gender: Marital Status: Employee’s Birth Date (MM/DD/YYYY): Birth Country:
Female Single Divorced Legally Separated
Male Married Widowed Common Law
Are you Hispanic or Latino? Yes or No - if Yes select from the following list: Citizenship Status:
Hispanic/Latino Central America Hispanic/Latino Dominican Other Spanish Culture
US Citizen Birth (Native)
Hispanic/Latino Mexican Hispanic/Latino Puerto Rican
US Citizen Naturalized
Hispanic/Latino South America Hispanic Latino Cuban
Permanent Resident
Please select one or more racial categories:
Non Resident Alien - Visa Type:
Asian Black White American Indian/Alaska Native Exp. Date:
Native Hawaiian/Other Pacific Islander
If you wish to voluntarily self identify your US Veteran status please indicate: Disability (Optional): Retired Public Employee:
Armed Forces Service Medal Veteran None Mobility
Are you a retiree of any public employer
Disabled Veteran Recently Separated Veteran Learning Multiple Impairments
Vietnam Era Veteran Military Discharge Date: Blind Other in the State/City of New York?
Other Protected Veteran Voluntary Firefighter?
Yes No Yes No
Part 4 Office Address and Phone
This information will be published in the Faculty Staff Directory
New employees DO NOT complete this section. The department will complete it for you.
Building
Building:: Zip+4: HSC/UH Floor: Room #:
Office Phone: Office Phone 2: Office Fax: Pager Number:
HRSF0019 (12/10) Page 1 of 2 www.stonybrook.edu/hr
Part 5 Skills/Credentials
Language Skills (Optional):
ID Badge Data (Credentials):
Part 6 Emergency Contact
If needed, more than one contact may be listed. International faculty and staff please include a local contact.)
Contact Name (Last, First): Contact Phone Number:
Relationship to employee (Optional):
Contact Name (Last, First): Contact Phone Number:
Relationship to employee (Optional):
Part 7 Prior NYS/RF Employment
Are you now or have you ever been employed by a New York State Agency or a State University of New York University: Yes No
If yes, Name of Agency/Campus: Start Date (MM/DD/YYYY): End Date (MM/DD/YYYY):
Are you currently employed by the Research Foundation? Yes No
Have you ever applied or attended Stony Brook University as a student? Yes No
Part 8 Education
Diploma/Degree: Year Earned: Major:
School, University or College: School Address (City, State, Country):
Diploma/Degree: Year Earned: Major:
School, University or College: School Address (City, State, Country):
Part 9 Additional Documents Required for Appointment
(Departments Please indicate additional information required from the employee)
Valid New York State Driver’s License Copy of Degree
Valid NYS Commercial Driver’s License Copy of License/Professional Certification
Other:
Part 10 Certification
I certify the information, which I have provided, is complete and accurate to the best of my knowledge.
Employee Signature Date
HRSF0019 (12/10) Page 2 of 2 www.stonybrook.edu/hr
