KU Ombuds Office Intake Form

The Ombuds Office provides impartial, independent and confidential support services to all members of KU community. 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 students, staff, and faculty at KU. As with other information you share during a visit with the Ombuds, confidentiality will be maintained by our staff.

General Information: First Name:*      Email:*      School/College:  Please Select Architecture & Design Business Education Engineering Journalism & Mass Communications Languages, Literatures & Cultures (Part of the College) Law Liberal Arts & Sciences Libraries Music Pharmacy Public Affairs and Administration (Part of the College) School of Arts Social Welfare     Department/Program:  Please Select     Non-Academic Unit:  Please Select Academic Administrative/Management IT Libraries Operations Research Student Services Support     Do you supervise one or more people?  Please Select Yes No     Have you contacted the Ombuds Office?   Please Select Yes No   Previous contact with the Ombuds Office?  Please Select Office Visit Group Training/Workshop     KU Community Membership:*   Administrator  Faculty – Tenure/Tenure Track  Faculty – Non Tenure Track/Lecturer/Academic Staff  Graduate/Professional Student  KU Alumni/Graduate  Post-Doctoral Researcher/Fellow  Relative of Student  Unclassified Staff  Undergraduate Student  University Support Staff  Other     Years at KU:  Please Select 0-5 6-10 11-15 16-20 21+   Last Name:*      Contact number:*      Race/Ethnicity:  American Indian or Alaska Native  Asian  Black  Bi-racial/Multiracial  Hispanic or Latino  Native Hawaiian or Pacific Islander  White  Other     Gender Identity:   Genderqueer  Cisgender Man  Non-binary  Transgender  Cisgender Woman  A gender expression not listed here (please specify)  Agender  Trans Man  Trans Woman  Demi Gender  Two Spirit  Prefer Not To Say     Preferred Personal Pronoun:   Please Select He/Him/His They/Them/Theirs She/Her/Hers Xe/Xir/Xirs Ze/Zir/Zirs Other     Age:  Please Select Under 18 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 or Older

Request for Assistance: Referred by:*  Please Select Academic Advisor Professor/Instructor DEIB Sr Administrator Title IX Office Colleague HR Ombuds Presentation Self/None Student Housing Supervisor Union Website Other or Unknown   Nature of Issue:*  Please Select 1. Academic Matters 2. Accommodations 3. Career Progression and Development 4. Censure 5. Compensation & Benefits 6. Departmental Training 7. Disability, Temp or Perm, Reasonable Accommodation 8. Discipline/Probation 9. Discrimination 10. Evaluative Relationships 11. Expulsion 12. Financial 13. Harassment 14. Housing 15. Legal, Regulatory, Financial and Compliance 16. Organizational, Strategic, and Mission Related 18. Peer and Colleague Relationships 19. Request for Training/Workshop 20. Safety, Health, and Physical Environment 21. Services Practices 22. Services, Administration 23. Students Service Practices 24. Suspension 25. University Policy/Appeals 26. Values, Ethics, and Standards 27. Warning 28. Withholding Grades   How did you hear about Ombuds Office?  Internet Search  KU Bus Sign  Referred by another KU office or colleague  Social Media  Workshop/Training/Orientation  Other   Reasons for coming to the Ombuds office:*   Unfair Treatment  Need Information  Raise a Concern  Discuss Possible Options  Other     Have you consulted anyone else about this issue?  Please Select Yes No   If yes, who did you consult? Please Select Advisor CAPS Department Dean/Chair/Supervisor HR IOA Jayhawk SOS RA/RD Student Account Services Student Affairs Other   How do you prefer we contact you?*  Please Select Email Home Work

Acknowledgement: The Ombuds Office is a confidential, independent resource authorized to informally address faculty, student, and staff concerns from a neutral position, ultimately facilitating the process of conflict resolution. All interactions with the Ombuds are strictly confidential except cases where there is consent by complainant; imminent harm to the complainant, others or University; or a legal concern. The Ombuds does not operate as an advocate for individuals or the University, but as an advocate for fairness of outcomes. The Ombuds is an independent entity and reports directly to the Office of the Provost. The Ombuds works informally to achieve fair and equitable solutions to concerns; we are not licensed attorneys. By clicking on Submit Form, you are acknowledging that you understand that the Ombuds Office is NOT an office of notice.