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  • BWC OMBUDSPERSON SERVICES Intake Form

    🔒 Strictly Confidential • Off the Record • Not for Distribution Guided by IOA Standards of Practice Independence Neutrality Confidentiality Informality Voluntariness

  • ▲ CONFIDENTIALITY NOTICE — Please Read Before Proceeding
    This form is strictly confidential and off the record. It is received solely by the BWC Ombudsperson and is never shared with Jefferson Lab management, Human Resources, Legal, or any other party. Submitting this form does not constitute a formal complaint, grievance, or report, and creates no record in any employee personnel file.

    The only exception to confidentiality is an imminent risk of serious harm to you or others. Participation is entirely voluntary. You may stop at any time and your decision to contact the Ombudsperson will not be used against you in any way.

  • 1. Your Information

    Optional — you may use a preferred alias or leave blank to remain anonymous
  • Work Arrangement (optional)
  • General Role Level

  • Strictly Confidential - Off the Record - Not for Distribution - BWC Form 

  • Page 1 of 4 Intake Form | CONFIDENTIAL

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  • 2. Contact Preferences

    How would you like the Ombudsperson to reach you? All contact is confidential.
  • Format: (000) 000-0000.
  • Preferred Contact Method - Select the channel you feel most comfortable using for follow-up.

  • Privacy note: Contact information you provide is held exclusively by the BWC Ombudsperson. It is never shared with Jefferson Lab, stored in any Lab system, or used for any purpose other than responding to your inquiry. You may contact us without providing any contact information at all.

  • 3. Nature of Your Concern

    Select the category that best describes your situation. You can share more with the Ombudsperson directly.
  • Primary Concern Category - Select all that apply. You do not need to share details here — the Ombudsperson will explore this with you privately.

  • Strictly Confidential - Off the Record - Not for Distribution-BWC Form 

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  • Brief Description

    In a sentence or two, describe what you'd like to discuss. You don't need to share details here — the Ombudsperson will explore this with you privately. Please do not include names or identifying information about others.

  • ✔ Urgent concern? If you are experiencing an immediate safety threat, harassment, discrimination, or retaliation, please call the confidential Ombudsperson line directly at 301-883-1305 for a response within 4 hours. You may also complete and submit this form.

  • 4. Meeting Preferences

    How would you prefer to meet? All formats are equally confidential.

  • Preferred Meeting Format

    Select the format that feels safest and most accessible to you.
  • Select the format that feels safest and most accessible to you.

  • Scheduling Notes (optional)

    Any days, times, or constraints we should be aware of? Time zone if fully remote?

  • 5 Review & Acknowledgement

    Please review your information and acknowledge the confidentiality statement before submitting.
  • CONFIDENTIALITY ACKNOWLEDGEMENT

  • Strictly Confidential - Off the Record - Not for Distribution-BWC Form 

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  • Intake Form | CONFIDENTIAL

  • Schedule A Virtual Meeting

  • This meeting is a confidential, informal conversation designed to provide a safe and neutral space for you to discuss workplace concerns, ask questions, or explore options for resolving challenges. The Ombudsperson does not take sides or make decisions but supports fair processes, respectful communication, and constructive resolution.

    During this session, you can expect:

    • A private and off-the-record discussion
    • Clarification of your concerns and desired outcomes
    • Guidance on available options and next steps
    • Support in navigating workplace dynamics or conflicts

    Please note:

    • Participation is voluntary
    • This service is independent of formal HR processes
    • No records are placed in employee files

    Our goal is to help address concerns early, promote understanding, and support a healthy, respectful workplace.

  • This form creates no record in your Jefferson Lab personnel file and is not shared with management, HR, or Legal.

  • Strictly Confidential - Off the Record - Not for Distribution-BWC Form 

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