KU Ombuds Intake Form
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: 
 
 
Department/Program: 
 
 
Non-Academic Unit: 
 
 
Do you supervise one or more people? 
 
 
Have you contacted the Ombuds Office?  
 
 
 
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: 
 
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:  
 
 
Age: 
 
 
 
Request for Assistance:
Referred by:*   
Nature of Issue:*   
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?   
If yes, who did you consult?  
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 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.