Ombuds Complaint Form

Name Name * Title First Last Suffix
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Preferred Phone Preferred Phone - ### - ### ####
Alternate Phone Alternate Phone - ### - ### ####
Email *
The Office of the Ombudsperson hours of work are Monday to Friday, 8:30am-4:30pm (EST). Please indicate the best method and time to contact you for information (Check all that apply)
Method *

Method Preferred Phone Alternate Phone E-mail
Time(s) for Preferred Phone
Time(s) for Alternate Phone
What department or office is your question or complaint about? (Please identify by name) *
Who have you dealt with in this department or office with respect to your complaint? *
Please summarize the matter you are complaining about and include any relevant dates *
Summarize what steps you have taken to try and resolve your complaint including any grievance, appeals and/or requests for reconsideration you have submitted and what response you received *
If you have received a final decision on an appeal or request for review or reconsideration of your complaint, please indicate what the result was and why you feel this was unfair
If you consider the matter urgent, please explain why