Career Development Registration Form

Please complete and return this form to enable our staff to better assist you with career counseling and job search coaching. All information you provide is confidential and will be treated as such.

* Date (mm/dd/yyyy):

* First Name

* Last Name

* Employee ID Number:

* Total years of employment at UK:

* Specific department where you are currently employed:

* Major division/sector/college where currently employed (for example: UK Hospital, College of Arts & Sciences, etc.):

* Current job title:

* Start date (month/year) in current position:

* Current position grade:

* Work phone:

* May we contact you at this number?

Yes

No

* E-mail address:

* May we contact you at this e-mail address?

Yes

No

Campus mailing address

* Office number and building name (or street address)

* Department name

* City

* State

* Zip Code

Other employment at UK (if applicable)

Job title & position grade:

Department:

Approx. Dates (mm/yy):

Job title & position grade:

Department:

Approx. Dates (mm/yy):

Job title & position grade:

Department:

Approx. Dates (mm/yy):

Employment outside UK

Job Title:

Organization/Company:

Approx. Dates (mm/yy):

Job Title:

Organization/Company:

Approx. Dates (mm/yy):

Job Title:

Organization/Company:

Approx. Dates (mm/yy):

Education/Certification/Training

* Briefly list the highest level of formal education you have obtained and any other relevant continuing education, certifications, SAP, supervisory or professional development Training:

A Little More About You

* 1) What is prompting you to seek career assistance at this time?

* 2. What outcomes do you hope to achieve as a result of career counseling and/or job search coaching?

* 3. What are your current career goals? (However uncertain, list any thoughts that you might have.)

4. If you could obtain any specific position(s) or types of jobs at U.K., what would be some examples?

* 5. Do you have a preference for working on Campus or in the Healthcare Enterprise?

* 6. What barriers do you believe are getting in the way of meeting your career goals?

* 7. What personal strengths and external support in your life will help you achieve your goals?

8. Please rank order the values that are most important to you in your work (with 1 being the most important). Feel free to rank only those that apply (or that matter most to you).

	Achievement
	Creativity
	Helping others
	Helping society
	Practicality/usefulnes
	Environment
	Money
	Status/recognition
	Free time/leisure
	Work alone
	Leadership
	Job tranquility
	Intellectual stimulation
	Self-direction
	Risk-taking
	Stability
	Security
	Variety
	Authority
	Public contact
	Work as part of a team
	Competition
	Challenge/adventure
	Independence
	Fast pace

* Indicates Response Required