By: Source: AARP.org Date Posted: 2005-06-22 12:42:01
(*) denotes a required field
Why do you want to be an Ombudsman volunteer?
1. Are you available and willing to work approximately 4 hours a week (Monday through Friday) during working hours (8 a.m. - 5 p.m.)? Yes No Comments
2. Are you willing to complete the required written reports? Yes No
3. Have you ever been convicted of a crime other than minor traffic violations? Yes No If 'yes' please explain:
4. Previous Volunteer Experience:
5. Current Employer (if applicable, Name/Address, Phone, Your Position):
6. Skills and Experience:
7. Please list three (3) personal references who can attest to your character: (no relatives please) Name/Address, Phone, Relationship, # Years Known Name/Address, Phone, Relationship, # Years Known Name/Address, Phone, Relationship, # Years Known
8. Do you have any conflict of interest that could interfere with advocating for older individuals living in long-term care facilities? Yes No Explain:
9. Have you worked in a long-term care facility in any capacity in the last three (3) years? Yes No If 'yes' please describe:
10. Do you or an immediate family member have a financial interest in a long-term care facility (e.g., owner, employee, partnership, stockholder)? Yes No If 'yes' please explain:
11. Have you ever had a relative in a nursing home or assisted living facility? Yes No
12. If 'yes', did it influence your decision to become an ombudsman? If 'yes' why?
13. Are you a guardian, conservator or power of attorney for a nursing home or assisted living resident? Yes No If 'yes', please give the name of the facility:
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