Itasca Area Schools Collaborative - 316 Personnel Questionnaire-Website

316 Personnel Questionnaire-Website

Assigned To: Public User

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Please answer the questions below.

Personnel Questionnaire

Note: Information on the form will be sent to the Minnesota Department of Human Services pursuant to M.S. 256.998.

First Name:

First Name: required

Middle Initial:

Last Name:

Last Name: required

Email Address:

Email Address: required

Birthdate:

Birthdate: required

Gender:

Male
Female
Gender: required

Social Security Number:

Social Security Number: required

Ethnicity (This area is not required)
Hispanic or Latino?

YesNo

Race (This area is not required)

American Indian/Alaskan Native	Asian	Black/African American
Native Hawaiian/Pacific Islander	White

Are you a full time High School student?

YesNo

Are you a full time College student?

YesNo

Are you a TRA Annuitant? (retired from TRA)

YesNo

Are you a PERA Annuitant? (retired from PERA)

YesNo

Emergency Contact 1 Name and Phone Number:

Emergency Contact 2 Name and Phone Number (Optional):

Electronic Signature

Signature is required
By typing in your name (your “eSignature”), you accept and consent to be legally bound by this document’s statements, terms and conditions as if this document was signed by you in writing with pen on paper. You agree that no third party or other means of verification is necessary to validate your eSignature and that the lack of such third party or other means of verification will not in any way affect the enforceability of this document.

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Equal Opportunity Employer

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History

Step: Someone fills out the form
Sent To: Public User, On: 4/5/2025 7:26:38 PM Central Standard Time