Free Form 02OM003E (SUOA-S-77) - Oklahoma

*02OM003E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES Oklahoma Long-Term Care Ombudsman Program

Ombudsman Volunteer Application
Name Street address Place of employment City Social Security number State Zip Date Phone Phone

Area code Area code

Skills/special interests:

Hobbies:

Educational/special training:

Activities/organizations:

Do you drive? Yes Name Street address

No

Do you have liability insurance? Yes Area code City State Zip Phone

No

In case of emergency notify:

Issued 11-1-2006

02OM003E (SUOA-S-77)

Page 1 of 2

02OM003E (SUOA-S-77)

Ombudsman Volunteer Application

State briefly why you want to volunteer in the Ombudsman program.

I agree to abide by the rules and guidelines of the Oklahoma Ombudsman Program. I will not disclose information to anyone regarding any complainant or client's name, condition, or situation, except to the State Ombudsman or my supervisor, without the written permission of the complainant, client, or legal representative. Any release of information requires supervisory approval. I understand my application will be screened by Ombudsman program staff and that I must obtain training and accept supervision in order to be certified as an Ombudsman volunteer.

Signature Return this completed form to:

Date

the area Ombudsman supervisor at your Area Agency on Aging. Call 800-211-2116 for mailing address; or: State Long-term Care Ombudsman Program OKDHS - Aging Services Division 2401 NW 23rd Street, Suite 40 Oklahoma City, OK 73107 405-521-6734

Page 2 of 2

Issued 11-1-2006