Western Dubuque County Community School District
Employee/Substitute Emergency Contact and Affirmative Action Form
2/17/2019
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EMPLOYEE/SUBSTITUTE EMERGENCY CONTACT AND AFFIRMATIVE ACTION FORM

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Completion of items on this form not marked by an asterisk are optional.

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Employee/Substitute Last Name
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Employee/Substitute First Name
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Middle Initial
Female  Male  
Please select Gender
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SECTION I:

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In the event of an emergency, every effort will be made to reach your emergency contact person. It is your responsibility to keep this information up to date with the central administration office.
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Name of Emergency Contact Person

Emergency Contact Relationship
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Emergency Contact Phone Number(s)
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SECTION II (OPTIONAL):

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We would appreciate it if you would supply the following information. In order to comply with regulations established by the U.S. Equal Opportunity Commission, the Office of Civil Rights in the U.S. Department of Education, Iowa Code section 19B.11, and I.A.C. 281-ch.95, the District must report statistical summaries of the information requested below. The information is used for this purpose and other affirmative action purposes only.

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Yes  No  
Are you Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin regardless of race)
Race:
Please select your Race:
Yes  No  
Do you have a Disability?
Yes  No  
Are you a Disabled Veteran?
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Comments (Optional):
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Routing Instructions
Please route this form to the Payroll Department.
Complete the information below to route your form. * Indicates Required Fields
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.