Ombudsman Volunteer Application

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Arkansas State Long-Term Care Ombudsman Volunteer Visitors Program Application

Name/Address:

Home Phone:

Work Phone:

Email Address:

Birthday Month and Day

Tell Us About Yourself

1. Why do you want to become an Ombudsman Volunteer Visitor?

2. How did you first learn about volunteering with the Ombudsman Program?

3. How many hours a month/week are you available to volunteer with the Ombudsman Program?

4. What time of the day and which days do you prefer to volunteer?

5. Are you presently employed?

If employed, how many hours a week do you work?

6. Which nursing home(s) are you willing to visit? Have you selected a nursing home to visit?

7. Have you ever been inside a nursing home?

If Yes, please describe your experience in the nursing home

8. Have you ever been inside a residential care facility?

If Yes, please describe your experience

9. Do you have relatives or friends closely connected with a nursing home or residential care facility?

If Yes, please explain possible relations/conflicts

9A. Have you ever been employed by a nursing home?

If Yes, How long did you work there? What were your job duties? Why did you leave?

10. Are you willing and able to make a one year commitment to volunteer with the Ombudsman Program?

11. What questions/concerns do you have about the volunteer position?

12. List any previous volunteer experience that you have had.

Please include the organization, your involvement and the length of time you volunteered

References

Please list two references that we may contact. These should not be relatives but could be teachers, employers or other community members.

Reference #1

List name, address, phone #, relationship to you and how this person knows you

Reference #2

List name, address, phone #, relationship to you and how this person knows you

Volunteer Assurances

As a volunteer Ombudsman, I understand that the program requires a commitment to the ideals of the program that have been explained to me and I provide assurances that I will comply with these ideals as stated below:

I am at least 18 years old *

Yes

Required

I have reliable transportation, license and auto insurance *

Yes

Required

I agree to be impartial *

Yes

Required

I agree to be tactful, diplomatic and non-judgemental *

Yes

Required

I will be reliable and conscientious *

Yes

Required

I agree to be respectful of residents' preferences and cultural views *

Yes

Required

I am able to read and write and communicate in English *

Yes

Required

I will listen objectively without inserting my personal values when visiting residents *

Yes

Required

I have no family or friends residing in the facility that I will volunteer in *

Yes

Required

I agree to participate in a criminal background check *

Yes

Required

I understand that the work I do is confidential, *

I will not share any information about complaints, records, facilities, residents, or staff with anyone outside the Ombudsman program

Yes

Required

I agree not to express an opinion about the quality of specific long-term care facilities to the public, family or friends *

Yes

Required

I agree to complete the paperwork in a timely manner as identified by my supervisor *

Yes

Required

I do not have financial, personal or professional conflict of interest with long-term care facilities *

Yes

Required

Electronic Signature

Electronic Signature *

I understand by signing and dating this form I agree to everything on this form and that typing my name in the signature line is the same as my signature, which I will be required to give upon any job offer.

Yes

Required

Signature *

Type your name here

Today's Date *

Submit

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