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Ombuds Intake for Consultation
Office of the Student Ombuds at San Jose State University provides hybrid services. Consultation appointment (by phone or via Zoom) can be arranged after completing this intake form. E-mail:
ombuds@sjsu.edu
.
* Indicates required question
Email
*
Record my email address with my response
Last Name
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Your answer
First Name
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Your answer
Middle Initial
Your answer
Role
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Alumni
Community Member
Faculty
Parent
Staff
Student
Other:
Required
Student I.D.# (Please put "0" if not a student. For parent, please put your child's student I.D.)
*
Your answer
Gender Identity (for statistical purposes only, optional)
Female
Male
Nonbinary
Prefer not to say
Other:
Clear selection
Ethnicity: (for statistical purposes only - optional)
American Indian or Alaskan Native
Asian
Black or African American
Hispanic/Latinx
Native Hawaiian or Other Pacific Islander
White
Two or More Races
International Students (Non-Resident Alien)
Unknown
Decline to State
Other:
Clear selection
International Student
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Yes
No
Cell Phone Number
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Your answer
Home Phone Number
Your answer
Email Address
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Your answer
Preferred Method of Contact
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Choose
Cell Phone
Home Phone
Email
Live on Campus
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Yes
No
How did you hear about our Ombuds service/program?
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Search on web (website visits)
Campus tabling
Presentation
Friend/classmate/professor/colleague's suggestion
Walk-ins
Other:
Who/Which department referred you to this office? (If not applicable, please put "N/A")
Your answer
College (If not applicable, please select "Other" and put "N/A")
*
College of Business
College of Education
College of Engineering
College of Health and Human Sciences
College of Humanities and the Arts
College of Science
College of Social Sciences
College of Professional and Global Education - e.g. iSchool, MLIS, MSDA, etc.
Open University
International Gateways
Special Session (CPGE)
SJSU Online
Other:
Major (If not applicable, please put "N/A")
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Your answer
Course/Class Involved (If not applicable, please put "N/A")
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Your answer
Professor (or staff) involved if applicable
Your answer
Level (If not applicable, please select "Other" and put "N/A" or specify)
*
Freshman, Frosh - Undergraduate (1st year)
Sophomore - Undergraduate (2nd year)
Junior - Undergraduate (3rd year)
Transfer - Undergraduate (as a Junior, 3rd year)
Senior - Undergraduate (4th year)
Post-baccalaureate (e.g.: Credential)
Graduate
Doctorate
Other:
Anticipated Graduation Semester and Year (If not applicable, please put "N/A")
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Your answer
Date of Concern/Issue
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MM
/
DD
/
YYYY
Semester of Concern/Issue
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Your answer
What is the concern/issue? (Please briefly describe it with a few sentences)
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Your answer
Concern Category
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Admission
Advising
Basic Needs (finances, housing, health)
Classroom Climate/Teaching/Learning Process
Grades
Policies
Registration/Withdrawal/Evaluation
Student Conduct
Student Services
Other:
Required
What has been done to resolve this concern if any? What was the result?
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Your answer
What is your goal?
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Your answer
I hereby release to the Student Ombudsperson my academic records and any other information that may be pertinent to this informal consultation. Your agreement allows the Student Ombudsperson to share relevant materials with other involved departments or parties in order to direct your resolution process.
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Yes
No
I acknowledge the role of the Student Ombudsperson in issues and conflict resolutions by reading the SJSU Student Ombudsperson website information. (Please click this link to the page of the website to learn about it:
https://www.sjsu.edu/ombudsperson/about/what-is-ombuds.php
)
*
Yes
No
Send me a copy of my responses.
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