LTCO Application

PHOTO RELEASE
*

I authorize the Office of the Long-Term Care Ombudsman to use pictures of me for the purposes of recruiting volunteers and program outreach. These photos will not be sold or released to any other third party.I do not authorize the Office of Long-Term Care Ombudsman to take my photo.
Signature (click and drag with mouse to sign)*

Clear
Date*

MonthDayYear
Date

EMERGENCY CONTACT INFORMATION
Name*

First NameLast Name
Relationship:*
Phone Number*

Area CodePhone Number

REFERENCES

Please include four professional/non-family references
Reference #1*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reference #2*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reference #3*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reference #4*

First NameLast Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number

Please complete the information below, or upload your resumé here:

Browse Files

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VOLUNTEER EXPERIENCE
Name of Organization #1
Type of Organization
Job Title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Organization #2
Type of Organization
Job Title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Organization #3
Type of Organization
Job Title
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
WORK EXPERIENCE
Employer #1
Job Title
Job Duties
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer #2
Job Title
Job Duties
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Employer #3
Job Title
Job Duties
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
EDUCATION AND CERTIFICATIONS
Name of School
Area of Study/Major
Diploma/Degree Earned
Name of School
Area of Study/Major
Diploma/Degree Earned
Name of School
Area of Study/Major
Diploma/Degree Earned

FACILITY EXPERIENCE
Have you spent time (as a visitor, employee, volunteer, or any other role) in nursing facilities, adult foster care homes, residential care facilities, assisted living facilities, or continuing care facilities?*

YesNo
Facility Name #1
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Facility Name #2
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Facility Name #3
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Your Role
Comments regarding facility experiences:

TEAM MEETINGS

Certified Ombudsmen attend monthly team support meetings in their area. They are your best option for networking, connecting with your Deputy, receiving updates on program changes, and earning continuing education credits required to maintain your certification. If there is not a meeting scheduled in your area, you are strongly encouraged to attend the meeting held in a neighboring county. In addition, new meetings are added as volunteer numbers increase in other areas. If you cannot attend these meetings, an alternate plan will be necessary.
*Times and days are subject to change
Will you be able to attend monthly support meetings?*

YesNo

Will you be able to begin service within one month of certification?*

YesNo
• Certified Ombudsmen are appointed by the State Long-Term Care Ombudsman to act in accordance with the attached job description.

• A one-year minimum commitment is requested.

• Certified Ombudsmen commit to spending an average of sixteen hours a month on their ombudsman responsibilities, including weekday business hours.

• Certified Ombudsmen must complete six days of certification training including classroom sessions, a facility visit, and a certification test.

• Certified Ombudsmen must also complete 16 hours of continuing education annually.
Will you be able to fulfill the time commitments required by ORS 441.413 for the position?*

YesNo
Do you have reliable transportation so you will be able to make regular facility visits and/or attend meetings?*

YesNo
Will you be able to fulfill the duties of the applicable position description, including weekday daytime availability, facility visits, completing monthly reports, and requested length of service?*

YesNo

As a representative of the Office of the Long-Term Care Ombudsman, you will be a public official as defined by ORS 244.020(15. As a public official you must avoid conflict of interest or the appearance of conflict of interest and cannot benefit financially from your affiliation with the Office of the Long-Term Care Ombudsman. If a conflict develops after your appointment as a volunteer, you must notify the office immediately.
Have you been employed by or received remuneration from a nursing home, adult foster care home, assisted living facility, residential care facility, or continuing care facility in the past year?*

YesNo
Is any member of your household employed in a long-term care facility or receiving income from one?*

YesNo
Do you have any financial or fiduciary interest in a long term care facility, corporation, or partnership that owns long-term care facilities?*

YesNo
Are you currently employed by the Senior and People with Disabilities Division of the State of Oregon or an Area Agency on Aging, type B?*

YesNo

Consent to Reference and Criminal History Check

The checks will assist the Office of the Long-Term Care Ombudsman in making an informed decision about candidate qualifications. In assessing the pertinences of a conviction record, the agency will consider such factors as the nature of the crime, when and where it occurred, and the duties of the position for which application is made. The checks will be completed prior to the start of training.

I authorize the Oregon Long-Term Care Ombudsman (LTCO) to conduct a reference check with my present and/or previous employer(s) and/or volunteer positions, as well others I have listed who personally know me. I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, and employment history.

My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for volunteering at the LTCO, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers and references from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for volunteering as a representative of the State of Oregon.

I authorize the Office of the Long-Term Care Ombudsman to conduct a criminal history check and I agree to provide the office with the information necessary to complete the criminal record check.

I understand that any oral or written statement made during this process that is false, fraudulent, or misleading that is contained in this form or made in the course of any related application process, whether made by me or others at my request, will result in rejection of my application, denial of appointment to a volunteer position or dismissal if discovered after appointment.

This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
Full Legal Signature of Applicant (click and drag with mouse to sign)*

Clear
Date*

MonthDayYear
Date
The Office of the Long-Term Care Ombudsman retains the right to not approve an applicant for participation in the program or associated training sessions.
Should be Empty:

Long-Term Care Ombudsman Volunteer Application

ADDITIONAL INFORMATION

HOW DID YOU HEAR ABOUT US?

PHOTO RELEASE

EMERGENCY CONTACT INFORMATION

REFERENCES

VOLUNTEER EXPERIENCE

WORK EXPERIENCE

EDUCATION AND CERTIFICATIONS

FACILITY EXPERIENCE

TEAM MEETINGS