UNM Dispute Resolution Department
Confidential Data Sheet ____________________
(Please Print, Fill Out, Send or Drop off at:  Dispute Resolution, 1800 Las Lomas NE [Southeast corner of Buena Vista and Las Lomas] Parking available on Buena Vista)

SSN:______________________         Date: __________________  (leave blank)
Ethnicity:___________________        Initial Contact: written/phone/walkin
Gender: ___________________         Referred By: ___________________
Disability:__________________         1st Appointment:__________    (leave blank)
DOB: ____________________          Assigned To:_____________    (leave blank)

Name:_____________________________

Phone (Work):_________________       ___y/n

Phone (Home):________________         ___y/n
[Can we leave messages at this numbers, circle y/n?]

What Department are you in?:_______________________________

Do you have an E-mail address?  Please write it here:_________________

What is your Title?:__________________________  What is your Grade?:(     )

How long have you been in that position? ________
How long have you been at UNM? ________
Who is your Supervisor?(Name/Title):  _________________________________
Who is your Supervisor's Supervisor?(Name/Title) _______________________


(Reason for Seeking Our Services?)
 
 
 
 
 
 
 
 

Are you currently working with any other departments regarding this situation?
(If yes, Who?) ___________________