Fillable Personal Information Form - Non-Employee (Page 3 of 3) in pdf

WASHINGTON UNIVERSITY IN ST. LOUIS

Voluntary Personal Information – Non-Employee Postdoctoral Research Scholars Only

Name: _____________________________ ____________________ __________________________

First

Middle

Last

EMPLID: ____________________

Department: ____________________

Today’s Date: ____________________

The following questions are being asked of only Postdoctoral Research Scholars in compliance with the National Institutes of

Health (NIH) reporting requirements.

Race/Ethnicity:

____

Are you Hispanic or Latino?

Yes

And select all of the following that apply:

____

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. American Indian or Alaska Native – A person having

origins in any of the original peoples of North and South American (including Central America) and who maintains tribal affiliation or community attachment. Asian – A person having origins in any of the

original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and

Vietnam. Black or African American – A person having origins in any of the Black racial groups of Africa. Native Hawaiian or Other Pacific Islander – A person having origins in any of the original

peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Department Administrators: Please enter Race/Ethnicity in HRMS before mailing.

Disabled: ____

____

Yes

Individuals with disabilities are defined as those with a physical or mental impairment that substantially limits one or more major life activities.

Disadvantaged: ____

____

Yes

Individuals from disadvantaged backgrounds are defined as:

1. Individuals who come from a family with an annual income below established low-income thresholds. These thresholds are based on family size; published by the U.S. Bureau of the Census; adjusted

annually for changes in the Consumer Price Index; and adjusted by the Secretary for use in all health professions programs. The Secretary periodically publishes these income levels at

For individuals from low-income backgrounds, the institution must be able to demonstrate that such candidates (a) have qualified for Federal disadvantaged

assistance; or (b) have received any of the following student loans: Health Professional Student Loans (HPSL), Loans for Disadvantaged Student Program; or (c) have received scholarships from the

U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need.

2. Individuals who come from a social, cultural, or educational environment such as that found in certain rural or inner-city environments that have demonstrably and recently directly inhibited the

individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a research career. Recruitment and retention plans related to a disadvantaged background are most

applicable to high school and perhaps undergraduate candidates, but would be more difficult to justify for individuals beyond that level of achievement.

Send this page ONLY to Campus Box 8226, Attn: Mary Bradley

Personal Information Form - Non-Employee Page 3

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