Engineering Undergraduate Student Ombuds Intake Form

Please share your information with us so that we can contact you to start the ombuds process. You may also e-mail coeombuds@uta.edu to start the ombuds discussion.

Name - Your name and information will not be recorded. It is used simply to contact you to set up the initial meeting. Name - Your name and information will not be recorded. It is used simply to contact you to set up the initial meeting. First Last
UTA Student ID
UTA e-mail address
Preferred method of contact. Choose at least one.

Preferred method of contact. Choose at least one. Email to UTA email address Text message to phone number (enter preferred phone below) Phone call (enter preferred phone below) Other (alternate e-mail, etc.) Other (alternate e-mail, etc.)
Preferred phone number (Required if text or phone call was selected above) Preferred phone number (Required if text or phone call was selected above) - ### - ### ####
Classification - Note that the COE Ombuds currently works only with undergraduate students. Graduate students are recommended to contact their faculty advisor or their department advisor for assistance.

Classification - Note that the COE Ombuds currently works only with undergraduate students. Graduate students are recommended to contact their faculty advisor or their department advisor for assistance. Freshman Sophomore Junior Senior Second Bacc Other Undergraduate Other Undergraduate
Choose your current major. You may select more that one choice to indicate that you are a double major and/or pursuing an engineering minor.

Choose your current major. You may select more that one choice to indicate that you are a double major and/or pursuing an engineering minor. Aerospace Engineering Architectural Engineering Biomedical Engineering Civil Engineering Computer Engineering Computer Science Construction Management Electrical Engineering Industrial Engineering Mechanical Engineering Nuclear Engineering (minor) Resource and Energy Engineering Software Engineering Sustainable Engineering (minor) Undeclared Engineering UENG
OPTIONAL: General category of the issue
(select all that apply)

OPTIONAL: General category of the issue
(select all that apply) Academic Non-academic Policy / procedure Conflict Involves another student Involves a staff member Involves a faculty member Involves multiple people No other people involved
OPTIONAL: General Description of Issue
(Please do not include specific names or classes in this description. Those details will be discussed in conversation with ombudsman.)
OPTIONAL: Do you have a preference for who you would like to talk to regarding your issue? You may select one or more persons below or indicate no preference. We will do our best to match you with your preference but we cannot guarantee that your preferred ombuds will be available.
All members of the ombuds team can discuss any issue with you. Some ombuds members have special knowledge in certain areas if you would like to speak with those members.
See the ombuds website for more information about each ombuds team member.

You may request one or more preferred members of the ombuds team if desired:

OPTIONAL: Do you have a preference for who you would like to talk to regarding your issue? You may select one or more persons below or indicate no preference. We will do our best to match you with your preference but we cannot guarantee that your preferred ombuds will be available.
All members of the ombuds team can discuss any issue with you. Some ombuds members have special knowledge in certain areas if you would like to speak with those members.
See the ombuds website for more information about each ombuds team member.

You may request one or more preferred members of the ombuds team if desired: No preference Dr. Ishfaq Ahmad Dr. Alan Bowling Dr. Carter Tiernan