UCOP Ombuds 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,
will be maintained by our staff.
To assure confidentiality, your private contact number and email are recommended
Primary College/Work Area/Affiliation:
GUEA - Graduate, Undergraduate and Equity Affairs
Ethics, Compliance & Audit Services
External Relations and Communications
Human Resources Local
Human Resources Systemwide
System Wide Title IX Director
UC Affiliates (i.e. Vendors, campus, LLNL, etc.)
UC Agriculture & Natural Resources
UC National Labs
Affiliates (i.e. Vendors, campus, LLNL, etc.)
Years at UCOP or UC Location:
0 - 5
6 - 10
11 - 20
White/Middle Eastern/North African
Native American/American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Prefer Not to Say
A gender expression not listed here (please specify) Other:
Preferred Personal Pronoun:
17 and under
Nature of Issue:
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?
Campus Ombuds/Campus Affiliate or Resource
Ombuds Presentation / Training
Have you consulted anyone else about this issue?
Talked with colleague/friend
Discussed with someone on a higher level
Handled on own
Discussed w/ Dept Involved
Utilized Personal Therapist
How do you prefer we contact you?
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
, you are acknowledging that you understand that the Ombuds Office is NOT an office of notice.