Title:
Mr. Mrs. Ms. Miss Dr. Prof.

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

Zip:

Phone (home):

Phone (work):

Phone (mobile):

Email Address:

Which school/department does this concern?

What is the issue you'd like to have addressed?

What result would you like to achieve with your complaint?

To assist the District in ensuring that our services are provided to all members of the AISD community, we ask that you give us a little information about yourself. The completion of this information is optional and your responses will not affect the way in which your issue is handled.

Ethnicity:
African American American Indian Asian Hispanic White Other

Gender:
Female Male

Age Range:
16 - 25 26 - 44 45 +

How did you hear about the Austin School District Ombudsman?
Television
Newspaper
Brochure
AISD Media Services
AISD Website
Word of mouth
Other

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