Form Ohr-95 - Release Of My Personal Data printable pdf download

THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO

OFFICE OF HUMAN RESOURCES

RELEASE OF MY PERSONAL DATA

Name: __________________________________________ Badge Number:____________

(Print Last, First, Middle Name)

Job Title: _________________________________________________________________

By law (State of Texas Government Code section 552.024), employees may choose

whether to allow public access to their personal information that includes home address,

home telephone number, and information that reveals whether the employee has family

members.

By law (State of Texas Government Code section 552.117), commissioned peace officer

employees will have their personal information suppressed that relates to the peace

officer’s home address, home telephone number, or that reveals whether the employee has

family members.

By law (State of Texas Government Code section 552.021 and 552.023), employees are

entitled upon their request, to be informed about the information The University of Texas

Health Science Center at San Antonio collects about them. Under Texas Government Code

section 559.004, employees are entitled to have The University of Texas Health Science

Center at San Antonio correct information that is held and shown to be incorrect, in

accordance with the procedures set forth in The University of Texas System Business

Procedures Memorandum 32. The information that The University of Texas Health Science

Center at San Antonio collects will be retained and maintained as required by Texas

records retention laws and rules.

Social security numbers obtained by the Health Science Center are to remain confidential

regardless of the employee’s choice to allow public access to the other personal information

mentioned above. Social security numbers are required by the Health Science Center and

are used for verification of employment, payroll reporting, insurance administration, and

other employment-related processes.

Even if you suppress your personal information, you will still get the official documents you

need, such as your W-2 at tax time.

In accordance with Texas Government Code 552.024, I hereby make the following

selection (check one box below):

Yes

, I wish to allow public access to my personal information that includes my

home address, home phone number, and information that reveals whether I have

family members.

, I do not wish to allow public access to my personal information. This

information will not be published in the Health Science Center’s phone book and will

also be taken off the list of people our official vendors can contact with offers.

Signature: ______________________________________________ Date: _____________

OHR-95 (5/08)

Form Ohr-95 - Release Of My Personal Data