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:
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: 
UC Status:* 
 (Senate) Faculty
 Academic Non-Faculty
 Affiliates (i.e. Vendors, campus, LLNL, etc.)
 Career Staff
Years at UCOP or UC Location: 
 Black/African American
 White/Middle Eastern/North African
 Native American/American Indian/Alaskan Native
 Native Hawaiian/Pacific Islander
 Bi/Multi Racial
 Not Recorded
Gender Identity: 
 Cisgender Man
 Cisgender Woman
 Demi Gender
 Prefer Not to Say
 Trans Man
 Trans Woman
 Two Spirit
 A gender expression not listed here (please specify) Other:
Preferred Personal Pronoun: 
Nature of Issue:*   
How did you first hear about the Ombuds Office?
 Resource referral

 Campus Ombuds/Campus Affiliate or Resource
 Ombuds Presentation / Training
 Don't recall
 Not Recorded
Have you consulted anyone else about this issue?   
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 Submit Form, you are acknowledging that you understand that the Ombuds Office is NOT an office of notice.