Form Not Available Not Available OFCCP OMBuds Referral Form

OMB Control Number 1225-0088

[Expires XX/XX/YYYY]

Ombuds Service Referral Form

Completion of this form initiates communication with the Ombuds. 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, although the Ombuds will be unable to provide direct assistance unless you include your phone and/or email. 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, issue, or question you would like to address with the Ombuds. *

What are your goals for working with the Ombuds? *

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 Call

______ Video Conference

______ 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 form 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 [email protected] and reference OMB Control Number 1225–0088. Please do not return the completed form to this address.