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MON
8:30 AM
4:30 PM
TUE
8:30 AM
4:30 PM
WED
8:30 AM
4:30 PM
THU
8:30 AM
4:30 PM
FRI
8:30 AM
4:30 PM
SAT
CLOSED
SUN
CLOSED
Advising Intake Form
Name
*
First
Last
Student Number
Brock Email Address
*
Phone
Campus Extension
Permanent Mailing Address
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Summer Mailing Address
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland & Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Level of Study
Undergraduate
Graduate
International Student
Yes
No
Major
Year of Study
Gender
Female
Male
Trans
Prefer not to disclose
Before coming to the Ombuds Office, who did you speak with about your issue? Check all that apply
Classmate(s)
Teaching Assistant
Instructor/Professor
Chair/Program Director
Academic Advisor
Graduate Studies
Member of BUSU
Member of GSA
Associate Dean
Dean
Registrar's Office
Student Development Centre
Student Awards and Finance/Finance Department
Accessibility Services
Human Rights and Equity
No One
Other
How did you hear about the Office?
Academic Advisor
Chair/Program Director
Associate Dean
Registrar's Office
Instructor/Professor
Student
Friend/Family
Website
Presentation
Nature of Issue
Academic Misconduct Issue
Academic Misconduct Appeal
Non-Academic Misconduct
Re-evaluation of Grade
Grade Appeal
Probation/BOOST
Suspension Appeal
Debarment Appeal
Honours Standing
Accommodations
Interpersonal Issue with Supervisor
Interpersonal Issue with Instructor
Involuntary Withdrawal from Program
Complaint
Admissions
Readmission Post-Suspension
Do you have an appointment scheduled about this issue?
*
Yes
No
Parties Present
Date
Time
:
HH
MM
AM
PM
Room #
Please outline in point form, your reason for requesting Ombuds assistance: