Fillable APPLICATION FOR LONG TERM CARE OMBUDSMAN TRAINING (County of Lake)

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APPLICATION FOR LONG TERM CARE OMBUDSMAN TRAINING (County of Lake)

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Country of origin: US
File type: PDF

U.S.A. forms for County of Lake

BROWSE COUNTY OF LAKE (CA) FORMS

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AREA AGENCY ON AGING OF LAKE LONG-TERM CARE OMBUDSMAN PROGRAM
AND MENDOCINO COUNTIES, PSA26 OF LAKE & MENDOCINO COUNTIES
P.O. Box 9000 (16170 Main St.), Lower Lake, CA 95457 (707) 262-4525 FAX (707) 995-1081
APPLICATION FOR LONG TERM CARE OMBUDSMAN TRAINING
Last Name
First Name
Middle Initial
Date of Birth (mm/dd/yyyy)
Female
Street Address
Phone
City, State
Zip Code
Volunteer or Staff Long-Term Care Ombudsman Information:
Are you a paid staff member?
Yes No
Are you a volunteer?
Yes No
Occupation: (Check primary occupation)
Medical Business Education Clerical Technology Government
Financial Social Services Engineer Military Homemaker
Retired:
Yes No
Other (Specify):
Education
High School
Some College
College BS/BA
Postgraduate
Other (Specify):
Bilingual?
Yes No
Language(s) spoken:
Volunteer Experience
Please list any previous or current volunteer experience:
Driver Information
Are you available to drive anywhere in Lake and/or Mendocino Counties?
Yes No
If no, how far are you willing to travel?
Driver’s License # & State
Insurance Coverage
Liability:
Collision:
AREA AGENCY ON AGING OF LAKE LONG-TERM CARE OMBUDSMAN PROGRAM
AND MENDOCINO COUNTIES, PSA26 OF LAKE & MENDOCINO COUNTIES
P.O. Box 9000 (16170 Main St.), Lower Lake, CA 95457 (707) 262-4525 FAX (707) 995-1081
Supplemental Questions
Yes
No
Are you a provider of any services monitored by the California Long-Term Care
Ombudsman Program (i.e., do you own or are you employed by a Skilled Nursing
Facility, a Residential Care Facility, an Intermediate Care Facility, or an Adult
Health Care Facility)?
Are you related directly or by marriage to anyone who owns or is employed by any
of the above-named types of long-term care facilities?
If yes, does this facility come under the jurisdiction of the Ombudsman Program of
Lake & Mendocino Counties?
Do you presently work as a volunteer in any of the above named types of long-term
care facilities?
Do you feel that there is any other consideration which might constitute a potential
conflict of interest for you as an Ombudsman?
Why are you interested in becoming an Ombudsman?
References
I understand that an investigative background inquiry will be made on me which will include social
security, sexual offender, criminal and motor vehicle record searches. I hereby consent to your
obtaining the above information and that said information obtained will be kept confidential. I also
consent to submitting fingerprints for aforementioned background check.
______________________________________ _________________
Signature of Applicant Date
LTCOP USE ONLY
Approved Denied
Date:
By:
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APPLICATION FOR LONG TERM CARE OMBUDSMAN TRAINING (County of Lake)

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Completed 6 August 2020

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