OMBUDSMAN APPLICATION

Name*

Email

Phone*

How did you hear about OSCCSA?*

2. Have you ever worked for a long term care facility? If so, when was your last date of employment?*

3. Have you had any previous experience as a volunteer or are you currently volunteering with another agency? If so, what is the name of the agency and the nature of your volunteer work?*

Have you had experience working with older adults? If yes, please describe:*

5. Have you had any experience with long term care institutions (either as a visitor, work experience or a family member living in a facility)?*

List any languages spoken, other than English, and indicate your fluency.*

Are you willing to commit to completing the training and serve a two-month internship under the supervision of a certified Long Term Care Ombudsman? The training is a combination of online training, classroom training held here at our Concord office and time spent in facilities.*

Are you able to spend approximately 15 – 20 hours per month for one year as a volunteer with the Ombudsman program?*

Are you willing to attend at least 6 monthly in service meetings to meet the State recertification requirement of completing 12 hours of additional training annually?*

Email