Self Identification Form

EASTERN KENTUCKY UNIVERSITY SELF-IDENTIFICATION FORM (EKU Employees Only)
Eastern Kentucky University is required by law to report and maintain certain types of statistical information. In order to insure the accuracy of this information, all new employees are asked to self-identify. In addition, federal regulations concerning Medicare require the University to maintain information on spouses* of employees for purposes of determining benefits eligibility.
Please make an entry for each item listed below and certify the accuracy of this information with your signature.
1. Are you retired from the Kentucky Teachers' or Kentucky Employees' Retirement System? Yes No If yes, give effective date:
2. Do you currently have an active account with KTRS or KERS? Yes No If yes, give date initiated:
3. Have you ever been affiliated with EKU in the past? No Student Employee Other__________ If yes, give dates:
4. Date of Birth:	5. Sex: Female Male
(MM/DD/YYYY)
6. Home Address:	7. Phone: Home: Other:
8. Race: (Please Check)	9. US Citizen: Yes No
White Black Asian or Pacific Islander American Indian or Alaskan Native Hispanic Other	If no: Home Country: Original date arrived in US?
10. Veteran Status: (Please Check all that apply)
Non-Veteran, N/A Vietnam Era Veteran Special Disabled Veteran Other Eligible Veteran* please specify Other veteran Active Duty Military Separation Date: (mm-dd-yyyy)
11. Spouse's Full Name Date of Birth
12. Emergency Contact & Phone #'s: Name: Phone 1: Phone 2:
13. (Optional) Are you disabled? Yes No. If answer is yes, does your disability require any accommodation in order for you to perform the essential functions of your employment responsibilities?

14. I certify that the information above is correct and complete to the best of my knowledge.

NAME (Please print name as it appears on your social security card.)

SIGNATURE

SOCIAL SECURITY NUMBER

DATE
* You may request the qualifying campaign/expedition guide from Human Resources.