Ccf Health Care Ventures, Inc

CLEVELAND CLINIC HEALTH SYSTEM Facility: PERSONAL DATA SHEET

LAST NAME (Per SSN Card) FIRST NAME RESIDENTIAL ADDRESS (No PO Box)

CITY STATE ZIP Home Phone Number Cell Phone Number Home Phone Number Cell Phone Number PRIMARY PHONE XXX /XXX-XXXX SECONDARY PHONE XXX / XXX-XXXX MAILING ADDRESS (PO Box)

CITY STATE ZIP

IN CASE OF EMERGENCY, PLEASE NOTIFY: Primary Emergency Contact Information

LAST NAME FIRST NAME RELATIONSHIP Check this box if Address of your Primary Emergency Contact is same as your Residential Address.

ADDRESS

CITY STATE ZIP

HOME PHONE CELL PHONE

WORK PHONE EMAIL Secondary Emergency Contact LAST NAME FIRST NAME RELATIONSHIP Check this box if Address of your Secondary Emergency Contact is same as your Residential Address.

ADDRESS

CITY STATE ZIP

HOME PHONE CELL PHONE

WORK PHONE EMAIL

EDUCATION AND LANGAUGE

As Cleveland Clinic Foundation becomes a global organization, it is necessary to identify and record the skills and knowledge of Caregivers at the Cleveland Clinic, we would request that you answer the following questions.

No Academic credential High School or GED Trade Certificate HIGHEST EDUCATION LEVEL Professional Degree Some College Associate Degree Bachelor’s Degree Master’s Degree Doctorate Degree Ph. D EDUCATION LEVEL YEAR (Year in which highest education level was completed) MM/YYYY EDUCATION INSTITUTION SPECIALIZATION (Major) OTHER LANGUAGES

Version02: May 30, 2012 1 MARITAL STATUS

For benefits purposes, we would request that you complete the following. This data complements the information you will supply during your benefits enrollment and is only used for benefits purposes.

Single Married Legally separated Divorced Widowed

EMPLOYEE IDENTIFICATION DATA

Cleveland Clinic Foundation and its system hospitals are subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. To facilitate compliance with these laws, you are invited to voluntarily self-identify your gender, race and ethnicity and status as a veteran and/or individual with a disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information is kept confidential and is only used in accordance with the provisions of applicable laws, executive orders and regulations, including those that require the information to be summarized and reported to the federal government. When reported, data will not identify any specific individual. Cleveland Clinic and its system hospitals administers all terms and conditions of employment without regard to race, color, religion, gender, sexual orientation, gender identity, pregnancy, marital status, age, nationality, ethnicity, ancestry, disability, military status, genetic information, or status as a disabled or Vietnam era Veteran.

DATE OF BIRTH SS#

Self Identification

The Cleveland Clinic Foundation is a government contractor subject to Section 503 of the Rehabilitation Act of 1973, as amended, and the Vietnam Era Veterans' Readjustment Assistance Act of 1974, as amended, which require government contractors to take affirmative action to employ and advance in employment qualified disabled veterans, recently separated veterans, other protected veterans, and Armed Forces service medal veterans (collectively “covered veterans”) and qualified individuals with disabilities, If you have a disability or are a covered veteran we would like you to tell us so that you may be considered under our affirmative action program. You may inform us of your desire to be included in our affirmative action program at this time or at any time in the future. The information you provide will assist us in placing you in an appropriate position and/or in making accommodations for your disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with Section 503 of the Rehabilitation Act, as amended, or the Vietnam Era Veterans Readjustment Assistance Act of 1974, as amended.

The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions of the work or duties of individuals with disabilities and regarding necessary accommodations; (ii) first aid safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment; and (iii) government officials may be informed as required by law.

GENDER Male Female

DISABILITY Yes (See definitions over page) No

Hispanic or Latino

American Indian/Alaskan Native Caucasian RACE Black or African American Asian

Two or more races Native Hawaiian/Pacific Islander

No Service Active Reserve Inactive Reserve Disabled Veteran MILITARY STATUS (See definitions over page) Other Protected Veteran Armed Forces Metal Veteran Recently Separated Veteran

Definitions

Individual with a Disability - Definition

The term “disabled person” refers to an individual who (1) has a physical or mental impairment which substantially limits one or more major life activities, (2) has a record of such impairment, or (3) experiences difficulty securing, retaining, or advancing in employment because he or she is perceived to be disabled. Military Status - Definitions Disabled veteran means a disabled veteran who has the ability to perform the essential functions of the employment position with or without reasonable accommodation.

Other protected veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

Recently separated veteran means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval or air service.

Version02: May 30, 2012 2 Armed Forces service medal veteran means any veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Employee Signature: ______Date: ______

FOR HR COMPLETION ONLY

VISA TYPE (Complete for non US Citizens working in the US)

Exchange Visitor (J1)

Immigrant (IM)

Spouse/Child of a Student (F2)

Spouse/Child of Exc Worker (J2)

Student (F1)

Temporary for external US Svs (H2)

Temporary Worker (H1)

Document #

Expiration Date:

Country of Origin:

Correction Comments:

HR Signature: Date:

Applicant Signature: Date:

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