UCOP Ombuds Intake Form


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:
First Name:* 
 
Last Name:* 
 
 
Contact number:* 
 
 
Email:* 
 
 
Primary College/Work Area/Affiliation: 
 
 
UC Status:* 
 (Senate) Faculty
 Academic Non-Faculty
 Affiliates (i.e. Vendors, campus, LLNL, etc.)
 Alumni
 Campus
 Career Staff
 Contract
 Limited
 Retired
 Student
 Unknown
 
 
Years at UCOP or UC Location: 
 
 
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: 
Nature of Issue:*   
 
 
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?   
How do you prefer we contact you?*   
 
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.