1. Name*
  2. Date*
  3. Home Phone Number*
  4. Cellular Phone Number*
  5. Ivy Tech Email* (please only use your assigned Ivy Tech email)
  6. Student C# or Date of Birth*
  7. Gender*
    Male
    Female
  8. I consent for the Ombudsman to speak with an internal 3rd party regarding my concern.*
    Yes
    No
  9. Please check the area in which your concern fits. (check all that apply)*
    Class related
    Student/personal/family related
    Grade related
    Financial related
    Instructor related
    Staff related
    Student Organization related
    Ivy Tech related
    Other, please specify:
  10. Brief explanation of your concern: