Ombuds/Dispute Resolution Services For Staff


The Dispute Resolution Department is a Confidential Department: We do not use e-mail or auto fill forms as a form of communication. To protect your confidentiality, we ask that you print this form, fill it out, send or drop off at the Ombuds/Dispute Resolution Services For Staff (1800 Las Lomas NE [Southeast corner of Buena Vista and Las Lomas] Parking available on Buena Vista, our mail stop code is: MSC05 3140).


DR Case #: ____________________

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


Name:_____________________________       Department: __________________________________

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

Title:_______________________________  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?) ___________________