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Form W4 (Hmong) - Employee'S Withholding Allowance Certificate - University Of Wisconsin - Madison Page 4

Hmoob / Hmong

Kev Nug Nyias Qhia Nyias Kev Xiam Oobkhab

Rau Cov Neeg Ua Num Tshiab

(Disability Self‐Identification Survey For New Employees)

Npe (thov sau tus loj): ___________________________________ Naj Npawb Social Security: _____________________

Daim ntawv no nyob ntawm yeem. Caw txhua tus neeg ua num tshiab rau hauv tsev kawm ntawv kom qhia lawv tus

kheej rau hauj qab no. Nws yuav pab xyuas kom muaj kev txais ua num zoo rau cov neeg xiam oobkhab.

Kuv tsis yog ib tug neeg xiam oobkhab.

Kuv yog ib tug neeg muaj xiam oobkhab.

The Americans with Disabilities Act of 1990 (ADA) txhais tias ib tug neeg xiam oobkhab yog lub cev los kev xav tsis

ua haujlwm zoo uas ua nws ua tsis tau ib los ntau yam loj raws ib tug tib neeg ua tau. Cov ua piavtxwv ua tsis

tau ib yam loj: hnov lus, pom kev, hais lus, ua pa, ua num nyhav, mus kev, tu tus kheej, kawm los ua num.

[29 C.F.R. S1630.2(i)]

Kuv yog ib tug neeg muaj xiam oobkhab loj.

Neeg xiam oobkhab loj thwm tau tias tus neeg muaj mob loj yog qhov mob muaj txhua yam nram no:



Nws yog ua lub cev los kev xav tsis haujlwm los kev xav thiab lub cev sib txuam tsis ua haujlwm.



Nws yuav muaj/zoo li ntawd tas mus li.



Nws ua puas loj rau ib los ntau qhov kev loj ntawm ib tug tibneeg ua tau: tu tus kheej, mloog totaub thiab

hais tau lus, kawm, txav / co taus, nws nyob tau nws, thiab ua tau nws noj nws. (s.230.04 (9r)(a) 2., Stats.)

Tus neeg ua num npe kos: ____________________________________________________ Hnub: ___________________

Form W4 (Hmong) - Employee'S Withholding Allowance Certificate - University Of Wisconsin - Madison Page 4