Employee Data Form
Some of the information requested below is provided to the University System of Maryland and other State and Federal agencies as required by law. Data supplied to the USM offices is of a statistical nature only, with no direct reference to you. Please complete this form in full, and submit when complete.
Contact Information
Title (prefix)
Please select...
Dr.
Mr.
Mrs.
Ms.
Prof.
Other
Prefix (other)
First Name
Middle Initial
Last Name
County of Residence
Address
City
State
Zip
Home Telephone
Email Address
Personal Information
Date of Birth
Marital Status
Please select...
Single
Married
Divorced
Widowed
Separated
Common Law
Gender
Male
Female
Undeclared
Are you of Hispanic or Latino origin?
Yes
No
Race
Please select...
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Military Status
Please select...
Active Wartime or Campaign Badge Veteran
Disabled Veteran
Protected Veteran, but choose not to self-identify
Armed Forces Service Medal Veteran
Recently Separated Veteran
Not a Protected Veteran
Highest Level of Education
Please select...
Less than High School Graduate
High School Diploma or Equivalent
Higher Education (specify degree information below)
Highest Level Degree Code
Please select...
01 - 1 year of college
02 - 2 years of college
03 - 3 years of college
04 - 4 years of college
06 - Dr. of Bus. Admin.
07 - Bus. School Cert.
08 - Bus. School Work
10 - Cert. of Adv. Study
11 - Some College
12 - Dentistry
13 - Divinity/Ministry
14 - Dr. of Arts
15 - Dr. of Judicial Sci.
16 - Dr. of Laws
17 - Dr. of Musical Arts
18 - Dr. of Philosophy
19 - Dr. of Sci.
20 - Dr. of Social Work
21 - Dr. of Program Work
22 - Technical school
23 - Education
24 - 2 yr. college degree
25 - Bachelor's level degree
26 - Grad nurse with Masters
28 - Masters level degree
29 - Doctorate (academic)
30 - Doctorate (professional)
31 - Post-doctorate
32 - Master law
33 - Master program work
34 - Masters of fine arts
35 - Medical specialty work
36 - Medicine
37 - Optemetry
38 - Osteophathy
39 - Other Non-Medical Dr.
40 - Pharmaceutical Chemistry
41 - Podiatry
42 - Post Baccalaureate Degree
43 - Postdoctoral work
44 - RN (less than Bachelor's Degree)
45 - RN with Bachelor's
46 - Teaching Cert.
47 - Trade school work
48 - Trade school Cert.
49 - Veterinary Sci.
Highest Level Degree Type
Visa Status (if Non-US Citizen)
Please select...
N/A
A1 - Non-Resident w/Diplomatic Visa
A2 - Diplomatic Dependent Visa
AS - Asylee
B1 – Non-Resident w/ Visitor for Business Visa
B2 – Non-Resident w/visitor for pleasure visa
C1 - Alien in transit through US
CB - Citizen of U.S. Citizenship by birth, native citizen
CN – Citizen of U.S. by naturalization
DA - Deferred Action
E1 - Treaty Trader, spouse/children
E2 - Treaty Investor, spouse/child"
F1 – Non-Resident with student visa
F1T - Scholar- FICA
F2 - Spouse or child of F1
G1 - International Organization Representative
G4 – International organization representative
H1 – Non-Resident with faculty visa
H1B - H1B Specialty Occupations
J1 – Non-Resident w/exchange visitor visa
J1T - Scholar-FICA
J2 - Dependent of J-1
K1 - Fiancé of US Citizen
K3 - Spouse of US Citizen
L1A - Executive, Managerial
L2 - Dependent of L-1 Visa Holder
PP - Permanent Pending Immigrant
PR - Permanent Resident
R2 - Religious Visa
RF – Refugee
TN - NAFTA visa (Canada/Mexico)
TP - Temporary Protective Status
ZZ - Other Visa Type
Emergency Contact Information
Contact First Name
Contact Last Name
Contact Telephone
Contact Information