Welcome to UTMB!
New Employee Welcome Center
New Hire Information:
Please read all information. You will process with the New Employee Welcome Center during orientation
on June 22, 2011. Please note when completing forms that you may leave Employee ID blank since one has
not been issued yet.
1. You are required to provide original and unexpired acceptable documentation for the I-9
Employment Eligibility Verification form.
2. Your acceptable document(s) should be either (one) from “List A” OR (one from both) “List B
and List C." This is required by the Department of Homeland Security, U.S. Citizenship and
Immigration Services. Failure to comply will result in a delay in your hire date.
3. I-9 Employment Eligibility Verification Form (click to print I-9 Form)
Failure to comply with these federal guidelines by your 3rd day of employment can result in termination.
UTMB participates in the E-Verify system.
Payroll Information:
All new employees are entered with a W-4 designation of Single status with zero allowances, per Internal
Revenue Service standards.
As a UTMB employee you may update your information via the Employee Self Service option found on
the UTMB intranet website (http://intranet.utmb.edu/iutmb/), once you have been given your login
authorization (utmb-usersm access). Instructions are located at Completing a W-4.
Direct Deposit- UTMB strongly encourages all employees to use direct deposit for their payroll checks.
As a UTMB employee you may update your information via the Employee Self Service option found on
the UTMB intranet website (http://intranet.utmb.edu/iutmb/), once you have been given your login
authorization (utmb-usersm access). Instructions are located at Helpful Hints, or see FAQs.
Dependent on your start date and the date payroll is processed; you may receive your first paycheck via
check mailed to your home address, or by direct deposit. Please assure your home address is correct in
the Employee Self-Service option found on the UTMB intranet website (http://intranet.utmb.edu/iutmb/)
International Applicants: Please note the International Office has moved.
You must visit the International Affairs Office upon arrival located in the Department of Legal Affairs,
International Section, Rebecca Sealy Hospital, Suite 4.254.
Bring all documents pertaining to your Visa status. You may visit their website:
www.utmb.edu/international/ or call (409) 747-8731 for assistance.
Important Notice: All applicants are required to submit to a Security and Drug screening prior to employment,
a state-issued drivers license/ID is required by Employee Health to verify identification for pre-employment
drug screening. Clinic hours for drug testing are from 7:30 a.m. to 3:00 p.m. Applicants completing their New
Employee Packet in the Welcome Center after clinic hours will be instructed to report to the Employee Health
Clinic the following day. Please direct any questions to the New Employee Welcome Center at (409) 747-4800.
Recruitment 03/04/2011
PERSONAL INFORMATION
NAME____________________________________________________________________________________
LAST
FIRST
MIDDLE
ADDRESS________________________________________________________________________________
STREET
CITY
SSN# ____________________________
SEX ____MALE ____FEMALE
STATE
ZIP
DATE OF BIRTH______________________
NAME OF SPOUSE ( if applicable)______________________________
RACE/ETHNIC CLASSIFICATION
Are you Hispanic or Latino?
_________Yes ________No
What is your Race? Select one or more of the following:
_____ White: (not of Hispanic origin): Persons having origins in any of the original Europe, North African or
the Middle East.
_____ Black: (Not of Hispanic origin): Persons having origins in any of the Black racial groups of Africa.
_____ Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin, regardless of race.
_____ American Indian or Alaskan Native: Persons having origins in any of the original peoples of North
America and who maintain cultural identification through tribal affiliation or community recognition.
_____ Asian or Pacific Islander: Persons having origins in any of the peoples of the Far East,
South Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China,
Japan, Korea, the Philippine Islands, and Samoa.
If you selected multiple races, please identify your primary ethnicity (for reporting purposes).
_____White _____ Black _____ Hispanic _____ American Indian/Alaskan Native _____ Asian/Pacific Islander
MILITARY INFORMATION
Are you a U.S. Veteran? __________ yes ___________ no
Branch? ____________________________ Reserve Status? ______________________
Specify dates: From ________________ To _________________
Are you a Vietnam era veteran?
__________ yes ___________ no
Are you a Special Disabled veteran?
__________ yes ___________ no
Are you an other eligible veteran?
__________ yes ___________ no
Are you a widow(er) of a veteran?
__________ yes ___________ no
Are you an orphan of a veteran?
__________ yes ___________ no
INDIVIDUALS WITH DISABILITIES
If you wish to be identified as a disabled individual, you are invited to check the appropriate box:
I have a disability: __________ yes ___________ no
Page 1 of 2
FOSTER CHILDREN
Were you in foster care on the day preceding your 18th birthday?
__________ yes ___________ no
EMERGENCY CONTACT
NAME
____________________________________________________________________
ADDRESS
____________________________________________________________________
____________________________________________________________________
RELATIONSHIP
____________________________________________________________________
HOME
______________________________
WORK _____________________________
TEXAS STATE SERVICE INFORMATION
Are you a prior UTMB employee? ___________Yes __________No
If yes, dates(s) ___________________
Service with an Independent School District (I.S.D.), Junior College, or Community College does NOT qualify
you for State of Texas Services; therefore, service and accruals CANNOT be transferred from an I.S.D., Junior
College or Community College.
In order for any prior service to be credited to you for the purpose of “Longevity Pay” or “Increased
Accrual Rate” or Service Award Recognition” first we must be provided with the name(s) of any other
State of Texas Agency(s):
Are you a DIRECT TRANSFER from another State of Texas Agency?
If yes, which State of Texas Agency?
Have you ever worked for any other State of Texas Agency?
If yes, please tell us which agency(s):
Yes
Yes
No
No
Employee Signature_________________________________ Date__________
Printed Name ______________________________SSN __________________
Page 2 of 2
PUBLIC DISCLOSURE
Under the Vernon’s Annotated Statutes, Article 6252-17 (a), Section 3, the home address and
telephone number, social security number and number of dependents of UTMB employees are
considered to be public information. As a government employee, you have a right to withhold
from public access this information.
PLEASE CHECK ONE:
_____ I DO want my home address and telephone number, social security number and
number of dependents to be considered public information.
_____ I DO NOT want my home address and telephone number, social security number
and number of dependents to be considered public information
Employee Signature_________________________________ Date__________
Printed Name ______________________________SSN __________________
THE UNIVERSITY OF TEXAS MEDICAL BRANCH GALVESTON, TEXAS
Standards and Regulations for University Employment
To:
THE UNIVERSITY OF TEXAS MEDICAL BRANCH
I hereby certify that I have been furnished a copy of the following:
(copies available on-line or in the New Employee Welcome Center)
1. Excerpts from Current Appropriations Bill. “Political Aid and Legislative Influence
Prohibited.”
2. Standards of Conduct for State Officers and Employees (Excerpts from Acts 1973, 63rd.
Legislature, Page 1086, Chapter 421, Effective January 1, 1974.)
3. House Bill 1673, Article 8, Acts 66th. Legislature, 1979, Regular Session, State
Purchasing and General Services-Property Accounting.
4. The General Policy statement of the Patent Policy Regulations of the University of Texas
System as established in Part II, Chapter 5, and Subsection 2.4 of the Regents’ Rules and
Regulations.
5. Current Appropriations Bill, Article V, Section 9, statement on “Dual Employment with
the state.”
6. The University of Texas Medical Branch at Galveston Employee Guide can be accessed
from the UTMB home page or at www.utmb.edu/policy/ihop
Employee Signature_________________________________ Date _________
Printed Name_______________________________ SSN ________________
DRUG FREE WORKPLACE POLICY STATEMENT
The University of Texas Medical Branch at Galveston is required by the Drug-Free
Workplace Act of 1988 (41 U.S.C.A. Paragraphs 701-707), to notify all employees that
the University prohibits the unlawful manufacture, sale, distribution, possession or use of
a controlled substance by any employee in the workplace or in the course and scope of
his/her employment. A controlled substance is any substance so defined by federal or
state statute or regulations. Exceptions shall apply to the extent that the employee is
using such a substance pursuant to a valid prescription of other uses authorized by law.
Any employee who is found guilty (including a plea of no contest) or has a sentence fine
or other penalty imposed by a court of competent jurisdiction under criminal statute for
an offense involving a controlled substance that occurred in the workplace or in the
course and scope of his/her employment shall report such action to the Employee
Assistance Program within the Human Resources Department within five (5) days.
An employee who unlawfully manufactures, sells, distributes, possesses or uses a
controlled substance in or on premises in the workplace or in the course and scope of
his/her employment, regardless of whether such activity results in the imposition of a
penalty under a criminal statute, will be subject to appropriate disciplinary action,
including termination, or will be required to participate satisfactory in an approved drug
assistance or rehabilitation program or both.
Employee Signature ______________________________ Date ________
Printed Name ______________________________ SSN ______________
Political Aid. Legislative Influence, and Standards of Conduct
Provisions of the 1998 – 99 Appropriations Act.
Employment provisions in Article IX. Sections 5 and 6 of the current Appropriations Act require that the following
provisions be furnished to each employee. These sections also require that each employee acknowledge receipt of
this information.
Sec. 5 Political Aid and legislative Influence Prohib ited. None of the moneys appropriated by this Act,
regardless of their source or character, shall be used for influencing the outcome of any election, or the passage or
defeat of any legislative measure. This prohibition shall not be construed to prevent any official or employee of the
state from furnishing to any Member of the Legislature or committee upon request, or to any other state official or
employee or to any citizen information in the hands of the employee or official not considered under law to be
confidential information. Any action taken against an employee or official for supplying such information shall
subject the person initiating the action to immediate dismissal from state employment.
No funds under the control of any state agency or institution, including but not limited to state appropriate funds,
may be used directly or indirectly to hire employees or in any other way fund or support candidates for the
legislative, executive, or judicial branches of government of the State of Texas or the government of the United
States.
None of the funds appropriated by this Act shall be expended in payment of the salary for full-time employment of
any state employee who is also the paid lobbyist of any individual, firm, association or of a part-time employee who
is required to register as a lobbyist by virtue of the employee’s activities for institution for which the person is
employed. A part-time employee may serve as a lobbyist on behalf of industry, a profession or association as long
as such entity is not related to the agency with which he or she is employed.
Except as authorized by law, none of the funds appropriated by this Act shall be expended in payment of
membership dues to an organization on behalf of the agency or an employee of an agency if the organization pays
all or part of the salary of a person required to register under Chapter 305, Government code.
No employee of any state agency shall use any state-owned automobile except on official business of the state,
and such employees are expressly prohibited from using such automobile in connection with any political campaign
or any personal or recreational activity.
None of the moneys appropriated by this Act shall be paid to any official or employee who violated any of the
provisions of this section.
Sec. 6 Standards of Conduct for State Employees.
expended to pay the salary of a state employee who:
None of the funds appropriated by this Act shall be
1) accepts or solicits any gift, favor, or service that might reasonably tend to influence the employee in the
discharge of official duties or that the employee knows or should know is being offered with the intent to
influence the employee’s official conduct;
2) accepts other employment or engages in a business or professional activity that the employee might
reasonably expect would require or induce the employee to dissolve confidential information acquired by
reason of the official position;
3) accepts other employment or compensation that could reasonably be expected to impair the employee’s
independence of judgment in the performance of the employee’s official duties;
4) makes personal investments that could reasonably be expected to create a substantial conflict between the
employee’s private interest and the public interest; or
5) intentionally or knowingly solicits, accepts, or agrees to accept any benefit for having exercised the
employee’s official powers or performed the employee’s official duties in favor of another.
Employee Signature ______________________________ Date ________
Printed Name ______________________________ SSN ______________
Revised: July 2008
THE UNIVERSITY OF TEXAS MEDICAL BRANCH
VERIFICATION OF INFORMATION AFFIDAVIT
PLEASE PRINT ALL INFORMATION REQUESTED
NAME:
LAST NAME
FIRST NAME
MIDDLE INITIAL
SOCIAL SECURITY NUMBER:
I have reviewed my applicant profile, resume, and/or cv and I certify that all information
provided in the profile and application process is true, correct and complete to the best
of my knowledge and that I have not evaded or omitted any part to reflect an untruth. I
understand that falsification constitutes grounds for refusing or terminating my
employment at the University of Texas Medical Branch.
SIGNATURE:
DATE:
The University of Texas Medical Branch
AUTHORIZATION FOR PAYROLL DEDUCTION FOR OUT-OF-POCKET
INSURANCE COSTS
Name (printed): ______________________________________________
TO: BENEFITS CENTER
I understand that as a full time employee with the University of
Texas Medical Branch my Medical coverage is provided at no cost
to me; however, should I drop below 100% (full-time) status, the
University will only pay a portion of my insurance.
The remainder of the premiums due, that the University will not
pay, will be deducted from my paycheck.
If the status change occurs and I do not wish to keep my
insurances, I must notify the Benefits department within 31 days of
the status change.
________________________________
Signature
__________________
Date
Teacher Retirement System of Texas/Optional Retirement Program
Confirmation of Prior Participation
Name: ____________________________ SSN: __________________ Emp#: ____________
1. Have you ever worked in Texas for State supported universities, medical and dental schools,
junior/community colleges, public schools, regional education service centers, certain charter
schools?
Yes ____ No ____
If yes, where?
____________________________________________________________________________
____________________________________________________________________________
If YES, please complete the remainder of the form.
2. Did you contribute to TRS during this period of employment?
Yes ____ No ____
If YES, have you withdrawn your funds from TRS?
Yes ____ No ____
If NO, are you currently receiving a monthly retirement check from TRS? Yes ____ No ____
3. Have you ever elected the Optional Retirement Plan (ORP) in the state of Texas in lieu of
participating in TRS?
Yes ____ No ____
If YES, please list places of employment and dates of participation:
Place of Employment
______________________________________________
Signature
Dates
to
to
to
to
to
_____________________
Date
EMPLOYEE HEALTH QUESTIONNAIRE
Previous UTMB Employee [ ] No [ ] Yes Year____
Date:
UTMB ID#:
Last Name:
First Name:
MI:
Maiden Name:
Marital Status:
Date of Birth:
Sex:
Race:
UTMB Mail Route:
City:
State:
Zip:
Home Phone #:
Birthplace:
Job Title:
Department:
Duty Hours:
Work Telephone #:
[ ] Male [ ] Female
Home Address:
Supervisor:
The scope of my duties with UTMB does ___/does not ___ include direct contact with human blood, body fluids, and/or tissues.
The scope of my duties with UTMB does ___/does not ___ include direct interaction (that is, in the same airspace) with patients.
The scope of my duties with UTMB does ___/does not___ include direct contact with animals or chemicals (used for research),
radiological, isotopes, and/or toxins (research).
MEDICAL HISTORY:
List any current medical problems that require treatment or follow up:
List any current medications you take:
List any Medication Allergies you have:
List any Allergies other than to medications:
List any Medication you cannot take because of side effects or intolerances (exclude allergies):
List any surgeries/operations/or serious injuries you have had:
Check (√) any of the following you currently have, or ever had:
___ Epilepsy or Convulsions
___ Abnormal Color Vision
___ High Blood Pressure
___ Chronic Pain
___ Back Surgery
___ Tuberculosis Disease
___ Rubella (German Measles)
___ Hepatitis
___ Fainting or Dizzy Spells
___ Asthma
___ Diabetes
___ Fainting after Shots
___ Bone or Joint Problem
___ Chronic Infection
___ Measles
___ Other
___ Impaired Hearing
___ Heart Problem
___ Hernia
___ Back Pain or Spine Disorder
___ Positive TB Skin Test
___Chicken Pox
___Chronic Skin Problem
Comments:_________________________________________________________________________________________________
__________________________________________________________________________________________________________
I acknowledge the above answers and all other information otherwise given by me as true, complete, and not misleading in any way. I understand
that any incorrect, incomplete, misleading or false statements furnished by me will result in discharge from UTMB if I am employed. All
information will be held strictly confidential.
Signature:
Date:
Rev. 11/10/2006 skw
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