Healthy Families Indiana New Hire Profile Record  


 Note: The following information will be used to create a staff profile in the HFI Training Tracking Database. Please
 be sure this information is accurate.
 COUNTY:                 

     
 Last Name                                                                        First Name                                                    Middle Initial

 Email Address:          Gender:  

  Are you fluent in a second language? Yes    No    (If yes, what is it?):   

 Ethnicity:                   African   
                                   African American not of Hispanic Origin  
                                   American Indian/Alaskan Native
                                   Anglo/American
                                   Asian/Pacific Islander
                                   Hispanic/Latino
                                   Multi-Ethic
                                   Other (specify):   

 Position:                   FSS/FSW
                                  FAW/FRS
                                  FSS/FRS
                                   FSW/FSS Supervisor
                                   FAW/FRS Supervisor
                                   Program Manager
                                  Other (specify):   
           
 Agency Street Address                                  City                                                   Zip                 Cell Phone Number

  Office Phone Number:    Office Fax Number:     
  
  Highest Completed Education Level:

 Years if Relevant Job Experience:    years