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Ohio Department of Aging Ombudsman Associate Program - Application Form

If you would like to give your time as a volunteer ombudsman associate, please complete the application below. Applicants are screened by the appropriate regional program and may be asked to submit to a criminal background check. Each regional program trains their volunteers and prepares them to enter nursing facilities as an advocate. Volunteers complete 10 to 14 hours of training (including 2 hours in a nursing facility) and take a simple certification exam. Once certified, volunteers are assigned to a facility.

All fields, except where noted, are required.

Personal Information








Emergency Contacts (Please provide the name and phone number of two individuals we may contact in case of emergency).





Current Employment (Please note: Current employment with a provider of long-term care services creates a conflict of interest and disqualifies you from service as an ombudsman Associate.)







:



Other Information


If YES, please explain:


Training Availability (Please indicate your availability for training during the following times to aid your regional program in planning. Training may not be available at all times listed.)





References: (Please list three persons not related to you whom we may contact as references):










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