Ombudsman Intake Form

Ombudsman's Office

First Name *

Last Name *

Person completing the form *

Phone Number *

E-Mail

Student Name *

School Name *

Student ID# *

Student Grade Level *

What is this in reference to? *

Concern *

Briefly describe your concern (in 250 words or less)

Actions Taken *

What have you already done to try to resolve the problem?

Remedy Requested *

Attachments

Untitled 1

P.O. Box 30035
Charlotte, NC 28230-0035
Phone: 980-343-3000

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