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:
Email *
Last Name *
First Name *
Middle Initial
Role *
Student I.D.# (Please put "0" if not a student. For parent, please put your child's student I.D.) *
Gender Identity (for statistical purposes only, optional)
Clear selection
Ethnicity: (for statistical purposes only - optional)  
Clear selection
International Student *
Cell Phone Number *
Home Phone Number
Email Address *
Preferred Method of Contact *
Live on Campus *
How did you hear about our Ombuds service/program? *
Who/Which department referred you to this office? (If not applicable, please put "N/A")
College (If not applicable, please select "Other" and put "N/A") *
Major (If not applicable, please put "N/A") *
Course/Class Involved (If not applicable, please put "N/A") *
Professor (or staff) involved if applicable
Level (If not applicable, please select "Other" and put "N/A" or specify) *
Anticipated Graduation Semester and Year (If not applicable, please put "N/A") *
Date of Concern/Issue *
Semester of Concern/Issue *
What is the concern/issue? (Please briefly describe it with a few sentences) *
Concern Category *
What has been done to resolve this concern if any?  What was the result? *
What is your goal? *
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. *
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: *
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