Intake Form

The Ombuds Office provides impartial, independent and confidential support services to all members of UCOP community and its affiliates. We are focused on ensuring that all students, staff, and faculty are treated fairly and equitably. If you believe you have been treated unfairly, need information, or wish to speak to someone about a concern, please fill out this form, and you will be contacted to set up an appointment.

The information you report on this form will help prepare us for our meeting with you and will help us keep track of the type of issues facing our community. As with other information you share during a visit with the Ombuds, confidentiality will be maintained by our staff.

General Information: To assure confidentiality, your private contact number and email are recommended First Name:*    Last Name:*      Contact number:*      Email:*  (does not have to be your work email)     Primary College/Work Area/Affiliation:  Please Select GUEA - Graduate, Undergraduate and Equity Affairs Academic Affairs Alumni Ethics, Compliance & Audit Services External Relations and Communications Human Resources Local Human Resources Systemwide Investments System Wide Title IX Director UC Affiliates (i.e. Vendors, campus, LLNL, etc.) UC Agriculture & Natural Resources UC Finance UC Health UC Legal UC National Labs UC Operations Other     UC Status:*   (Senate) Faculty  Academic Non-Faculty  Affiliates (i.e. Vendors, campus, LLNL, etc.)  Alumni  Campus  Career Staff  Contract  Limited  Retired  Student     Years at UCOP or UC Location:  Please Select Not Applicable 0 - 5 6 - 10 11 - 20 >20 Not Recorded     Race/Ethnicity:*  Asian  Black/African American  Chicanx/Latinx/Hispanic  White/Middle Eastern/North African  Native American/American Indian/Alaskan Native  Native Hawaiian/Pacific Islander  White/European  Bi/Multi Racial  Other  Not Recorded     Gender Identity:   Agender  Cisgender Man  Cisgender Woman  Demi Gender  Female  Genderqueer  Male  Non-binary  Prefer Not to Say  Trans Man  Trans Woman  Transgender  Two Spirit  A gender expression not listed here (please specify) Other:     Preferred Personal Pronoun:      Age:  Please Select 17 and under 18-24 25-34 35-44 45-54 55+ Decline

Nature of Issue:*  Please Select 1. Compensation & Benefits 2. Evaluative Relationships 3. Peer and Colleague Relationships 4. Career Progression and Development 5. Legal, Regulatory, Financial and Compliance 6. Safety, Health, and Physical Environment 7. Services/Administrative Issues 8. Organizational, Strategic, and Mission Related 9. Values, Ethics, and Standards 10. Performance Issues 11. Management/Supervisory Effectiveness       How did you first hear about the Ombuds Office?  Colleague  Supervisor/Manager  Subordinate  Resource referral  Self  Callback  Campus Ombuds/Campus Affiliate or Resource  Ombuds Presentation / Training  Website  Don't recall  Not Recorded  Other       Have you consulted anyone else about this issue?  Please Select Talked with colleague/friend Discussed with someone on a higher level Handled on own Met/Spoke w/person Contacted HR Filed petition/formal Nothing yet CAPS/EAP/etc. Discussed w/ Dept Involved Family FSAP Utilized Personal Therapist Other   How do you prefer we contact you?*  Please Select Email Phone Both

Acknowledgement: The Ombuds Office is a confidential, independent resource authorized to informally address faculty, student, and staff concerns from an impartial position, ultimately facilitating the process of conflict management and resolution. All interactions with the Ombuds are strictly confidential except cases where there is consent by complainant; imminent harm to the complainant, others or UCOP community. The Ombuds does not operate as an advocate for individuals or UCOP and works informally to achieve fair and equitable solutions to concerns. The Ombuds is an independent entity and reports directly to the President's Executive Office. By clicking on Submit Form, you are acknowledging that you understand that the Ombuds Office is NOT an office of notice.