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?) ___________________