Form Ombudsman – Fill Out and Use This PDF

Family Information Form For Ombudsman

Service Member's Name

Rank/Rate

Dept/Division

Work phone #

( )

Work Email

Projected

Address

Rotation Date

Mailing Address:

Street, City, State and Zip

Closest Military Facility to

Home

New to San Diego Area?

Spouse's Name (if applicable)

Mailing Address:

(if different from

above)

Spouse's Contact Info

Email

Home Phone

(

)

Cell Phone

(

)

Work Phone

(

)

Name

Age

Date of Birth

Children's Info

Primary Emergency

Name

Phone

Email

Point of Contact

Secondary Emergency

Name

Phone

Point of Contact

Anyone Else you would

Name

Mailing Address

Email

like command information

and newsletters to be

sent to (e.g. parents)

Name

Mailing Address

Email

I authorize the Ombudsman to use this information for official purposes only. I understand ALL information is confidential

Signature:	Date:

THE OMBUDSMAN IS A SOURCE OF INFORMATION AND REFERRAL ON ANYTHING AFFECTING COMMAND FAMILY MEMBERS. THEY ARE NOT COUNSELORS, BUT MAY DIRECT THE FAMILY MEMBER TO THOSE THAT WILL PROVIDE THE SERVICE OR INFORMATION DESIRED. THIS MAY INCLUDE ISSUES SUCH AS EXCEPTIONAL FAMILY MEMBER PROGRAM (EFMP); SCHOOL LIAISON OFFICERS; AND MANY OTHER RESOURCES.

PURPOSE: INFORMATION IS USED TO PREPARE ORGANIZATIONAL LOCATOR, RECALL ROSTER, AND SIMILA ADMINISTRATIVE USES REQUIRING PERSONNEL DATA.

ROUTINE USES: CONTACTING APPROPRIATE PERSONNEL WHEN NEEDED WHILE FULFILLING THE DUTIES AND RESPONSIBILITIES OF AN OMBUDSMAN INCLUDING REFERRAL ON MATTERS AFFECTING COMMAND FAMILY MEMBERS.

DISCLOSURE: VOLUNTARY. HOWEVER, FAILURE TO PROVIDE THE REQUESTED INFORMATION MAY RESULT IN THE OMBUDSMAN'S FAILURE TO PROVIDE HIS/HER SERVICES TO THE SERVICE MEMBER AND THEIR FAMILY MEMBERS.

PRIVACY ACT STATEMENT: TITLE 5, U.S. CODE 552A - REFERENCE TO THE PRIVACY ACT, SECNAV 5211.5E - THE DON PRIVACY PROGRAM, NAVADMIN 295/10-PERSONAL INFORMATION OBTAINED OR MAINTAINED THROUGH OFFICIAL SOURCES MAY NOT BE USED FOR UNOFFICIAL PURPOSES. UNOFFICIAL INFORMATION SUCH AS COMMERCIAL VENTURES, ADVERTISEMENTS, PRIVATE SOLICITATIONS, FUNDRAISING ACTIVITIES, AND BIRTHDAY WISHES, MAY NOT BE DISSEMINATED THROUGH OFFICIAL COMMUNICATION NETWORKS. WITHOUT PRIOR CONSENT, CO'S MAY NOT RELEASE PERSONAL CONTACT INFORMATION TO INDIVIDUALS OR ENTITIES OUTSIDE THE COMMAND, INCLUDING SPOUSE CLUBS OR FAMILY READINESS GROUPS.

If this information changes, please contact your Ombudsman at (619) 545 1701. Thank you!