Ombudsman Notification Form

Date:

Indicates required fields *

Please indicate if you are a Faculty/Staff personnel or a Student

I am a* Faculty/Staff

Student

Faculty and Staff Information: (disabled section if you select Student)
the following fields are to be filled out by the Faculty or Staff only.

Fac/Staff Name:*

Fac/Staff Phone:*

* Student Issues/Complaints

* Student Referral to Ombudsman

Student Information: (disabled section if you select Faculty/Staff)
the following fields are to be filled out by the Student only.

Does this pertain to a certain course(s) of yours? * Yes No

I prefer a * Phone Call Appointment

General Information:
the following fields needs to be filled out by either Faculty, Staff, or Student

Student Name:*

Tartan ID:*

Best phone number to reach student:*

Academic Program Major:*

School Term:

Term *

Course* (ex BIS.130.02)

Campus Location:

Campus:*

Other

Issues, Complaints, or Reasons for Student Referral*

Human Validation

Please type the letters as you see them in the image above. The letters are case sensitive