OMBuds Service Referral Form

OMB Control Number 1225-0088

Expires 1/31/2024

Ombuds Service Referral Form

Completion of the form below will initiate communication with the Ombuds Service. You can expect to hear from the Ombuds within one business day upon receipt of this referral form. Please note that this is a confidential submission. Your contact information will not be shared with anyone outside of the Ombuds Service unless you’ve authorized the Ombuds to do so. Further, completion of the contact information section below is optional, but the Ombuds will not be able to provide direct assistance unless you include your phone and/or email. If you wish to submit your concerns anonymously, please provide as much information as you are comfortable sharing and click “Submit” at the bottom of the form.

Please provide a brief explanation of the concern, complaint or question that you would like to address with the Ombuds Service. *

What do you hope to achieve by working with the Ombuds Service? *

Speaking engagements and workshops delivered by the Ombuds may also be requested. If you are completing this form to request a presentation of some kind, please indicate who the presentation would be delivered to and the intended purpose.

What is your preferred method of communication? Please check all boxes that apply.

______ Phone Calls()

______ Skype

______ Email

Contact Information

Name ________________________________

Title _________________________________

Company _____________________________

Phone ________________________________

Email ________________________________

Address ______________________________

Submit

The Paperwork Reduction Act of 1995 provides that no person is required to respond to a Federal collection of information unless it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Responding to this survey is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N–1301, Washington, DC 20210 or email DOL_PRA_PUBLIC@dol.gov and reference OMB Control Number 1225–0088. Please do not return the completed survey to this address.