Form 02OM003E "Ombudsman Volunteer Application" - Oklahoma

What Is Form 02OM003E?

This is a legal form that was released by the Oklahoma Department of Human Services - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 13, 2021;
  • The latest edition provided by the Oklahoma Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 02OM003E by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Human Services.

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Download Form 02OM003E "Ombudsman Volunteer Application" - Oklahoma

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Ombudsman Volunteer Application
If this application is filled out by hand, please print clearly.
Volunteer Information
First name
M.I.
Last name
Date
OK
Mailing address, street or PO Box
City
State
ZIP code
Email address
Phone number
Place of employment
Work phone
Skills / special interests:
Hobbies:
Educational / special training:
Activities / organizations:
Do you drive?
Yes
No
Do you have liability insurance?
Yes
No
02OM003E
12/13/2021
Page 1 of 2
Ombudsman Volunteer Application
If this application is filled out by hand, please print clearly.
Volunteer Information
First name
M.I.
Last name
Date
OK
Mailing address, street or PO Box
City
State
ZIP code
Email address
Phone number
Place of employment
Work phone
Skills / special interests:
Hobbies:
Educational / special training:
Activities / organizations:
Do you drive?
Yes
No
Do you have liability insurance?
Yes
No
02OM003E
12/13/2021
Page 1 of 2
In case of emergency notify:
First name
Last name
Phone number
Address
City
State
ZIP code
State briefly why you want to volunteer in the Ombudsman program.
Signature
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
Date
Routing
Return this completed form to:
the area Ombudsman supervisor at your Area Agency on Aging.
Call (800) 211-2116 for mailing address;
or:
Oklahoma State Long-Term Care Ombudsman
Community Living, Aging and Protective Services (CAP)
Oklahoma Human Services
P. O. Box 53159
Oklahoma City, OK 73152
Email:
Ombudsman.intake.line@okdhs.org
Email:
William.whited@okdhs.org
02OM003E
12/13/2021
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