RFO Application

Residential Facilities Ombudsman Program

830 D St. NE, Salem OR 97301

(P) 844-674-4567 or 971-719-6475

(Fax) 503-378-6852

RFO.info@oregon.gov

The Residential Facilities Ombudsman RFO program is focused on improving the lives of persons who experience Intellectual and/or Developmental Disabilities.

There are several volunteer opportunities in this agency with different applications. If you are interested in applying for Oregon Long-Term Care Ombudsman LTCO program (advocates for elderly or disabled residents in assisted living and residential care facilities, nursing facilities, and adult foster homes) or the Oregon Public Guardian and Conservator OPGC program (serves as court-appointed, surrogate decision makers for adults incapable of making some or most of the decisions necessary for their basic care and safety), please go to oltco.org and choose the application you are most interested in.
Residential Facilities Volunteer Application

Thank you for your interest in becoming a volunteer for the RFO program – we look forward to reviewing your application!
I am applying for: (Please check all that apply)

RFO Certified OmbudsmanOther
Date Completed:

MonthDayYear
Date
Name*

Last NameFirst NameMI
Preferred Name:
Preferred Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:*
example@example.com
Your Preferred Phone Number*

Area CodePhone Number
Preferred Means of Contact*

EmailPhoneOther

EMERGENCY CONTACT INFORMATION
Name*

Last NameFirst Name
Relationship:*
Home Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Your preferred form(s) of communication are:

WrittenASLVerbal/SpokenBrailleAugmented Communication DeviceLanguage other than English

ADDITIONAL INFORMATION
Did you serve in the armed forces?

YesNo
If yes, branch of service?
Do you speak any additional languages?
If yes, please list.

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

Browse Files

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VOLUNTEER EXPERIENCE
Have you spent time (as a visitor, employee, volunteer, or any other role) in Intellectual/ Developmental Disabilities and/or Mental Health homes or facilities?

YesNo
If yes, please list the home/facility address, the dates, and your role below.

WORK AND/OR VOLUNTEER EXPERIENCE

Please list the place(s) you have worked and/or volunteered.
Name of Organization #1
Type of Organization
Type of Experience
Job Title
Start Date

MonthDayYear
Date
End Date

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

MonthDayYear
Date
End Date

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

MonthDayYear
Date
End Date

MonthDayYear
Date

EDUCATION AND CERTIFICATIONS

Please list any education, certifications, boards, or specialized trainings (i.e. CPR/First Aid, MH First Aid, OIS, Partners in Policy, etc.)

REFERENCES

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

Last NameFirst Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reference #2*

Last NameFirst Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reference #3*

Last NameFirst Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Reference #4*

Last NameFirst Name
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number

PHOTO RELEASE
I authorize the Residential Facilities Ombudsman Program 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 authorize the Residential Facilities Ombudsman Program to take my photo for the ID badge required for the positions of Certified Ambassador or Certified Ombudsman.I do not authorize the Office of Long-Term Care Ombudsman to take my photo.
Signature*

Clear
Date*

MonthDayYear
Date

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 (OLTCO) to conduct a reference check with my present and/or previous employer(s), 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*

Clear
Date*

MonthDayYear
Date
The Residential Facilities Ombudsman Program retains the right to not approve an applicant for participation in the program or associated training sessions.
Should be Empty:

Residential Facilities Volunteer Application

EMERGENCY CONTACT INFORMATION

ADDITIONAL INFORMATION

VOLUNTEER EXPERIENCE

WORK AND/OR VOLUNTEER EXPERIENCE

EDUCATION AND CERTIFICATIONS

REFERENCES

Conflict of Interest

PHOTO RELEASE

Demographics Information