*IMPAQ’s finance department assigns File/Employee ID Number(s) to new hire.

EMPLOYEE MASTER FILE PERSONAL INFORMATION

Name

Salutation First Name MI Last Name Suffix

Date of Birth

Social Security Number

Gender o Male o Female

Marital Status o Single o Married

Ethnicity o Hispanic or Latino o Not Hispanic or Latino

Race o American Indian or Alaska

Native o Native Hawaiian of Other

Pacific Islander

o Asian o White

o Black or African American o 2 or more races

PERSONAL CONTACT INFORMATION

Address

Street Address/Apt

City County State Zip Country

Home Phone

Cell Phone

Email Address

VETERANS STATUS

VETS100 o Vietnam Era Veteran o Recently Separated (1yr)

o Special Disabled Veteran o None

o Other Protected Veteran

VETS100A o Armed Forces Service Medal

Veteran o Recently Separated (3yr)

o Disabled Veteran o None

o Other Protected Veteran

VISA STATUS (if applicable)

Visa Type

Visa Number

Visa Expiration

Citizen Of

I-9 Citizenship

I-9 Eligibility Review Date

*IMPAQ’s finance department assigns File/Employee ID Number(s) to new hire.

Completed by Human Resources Only

Original Hire Date

Job Title

Division o Corporate o Survey Center

Location Columbia Washington, DC California Hawaii Remote

Employee Type o Regular Full Time - 40 hrs

(benefits) o Regular Full Time 30-39 hrs (benefits)

o Regular Part Time

20-29 hrs (benefits) o Regular Part Time 20 hrs

o Temp Project Hourly o Intern Hourly

o Intermittent Hourly

FLSA o Exempt

o Salary

o Non-Exempt

o Hourly

Annual Salary

Bonus (if applicable, specify

amount & when payable)

Supervisor

Home Department

Weeks of Vacation at hire

Referred By

WORK CONTACT

Work Phone

Fax

Work Wireless

Email Address

This person will be a corporate supervisor

EMPLOYEE INFORMATION FORM (Please Print) SUBMIT COMPLETED FORM TO HUMAN RESOURCES

I. Basic Information Name (Last, first, middle initial):

Date:

Home Address:

Home Phone Number: Other Phone Number:

Date of Birth:

Date of Hire:

Name of Manager:

II. Emergency Contacts Name: Relationship:

Daytime Phone Number: Other Phone Number:

Name: Relationship:

Daytime Phone Number: Other Phone Number:

HUMAN RESOURCES

Dated submitted to Human Resources: Initials: _____________ Date:

DIRECT DEPOSIT ACCOUNT INFORMATION

I

Employee Name Deltek ID #

authorize the direct deposit of all/or part of my semi-monthly IMPAQ International payroll checks, to

the following account(s):

Name as it appears on the account

Account Number $ Amount Only (not %)

Checking Savings

Account Number $ Amount Only (not %)

Checking Savings

Voided Check Attached: Letter from Bank Attached:

I understand IMPAQ International bears no responsibility once any funds have been deposited to this or

any account authorized by me. This information supersedes all previous account information.

Signature Date

Witness Date

New Employee Information

The information from this document is used for a public Staff Announcement. When completing this

form, include information/insight about yourself that you would like us to share with your colleagues.

Name

Date of Hire

University & Degree (fill in applicable fields)

University: B.A.

University: M.A.

University: Ph.D.

Years of Relevant Experience

Areas of Specialization (e.g. LTC, labor, health, etc.)

Quantitative Skills (e.g. Stata, SAS, etc.)

Qualitative Skills (e.g. Focus groups, surveys, etc.)

Languages

Additional Information (optional)