Form 02OM005E "Conflict of Interest Statement and Ethical Guidelines for Supervisors" - Oklahoma

What Is Form 02OM005E?

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 14, 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 02OM005E 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 02OM005E "Conflict of Interest Statement and Ethical Guidelines for Supervisors" - Oklahoma

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Long-Term Care Ombudsman Program
Conflict of Interest Statement and Ethical Guidelines for Supervisors and Volunteers
General Information
General Information
The Older Americans Act Amendments of 1987 requires assurances that there is no conflict of
interest within the Ombudsman Program. Our mandate is to establish mechanisms to identify and
remedy any such conflict. To this end we ask that you study this document and sign it if you are
able to provide the following assurance and meet the following ethical guidelines:
1. No Ombudsman or member of the Ombudsman’s immediate family may own, operate, control,
or have interest, voting rights, or outstanding indebtedness to or be employed by any
company or facility or individual investigated by the Ombudsman.
2. No Ombudsman can serve as an Ombudsman in the Planning and Service area in which they
have been employed by a long-term care facility in the previous twelve months.
3. No Ombudsman may solicit or accept from any person or organization directly or indirectly,
money or anything of value if it could reasonably be expected to influence such Ombudsman’s
official actions or judgment or could reasonably be considered as a reward for any official
action or omission on the part of the Ombudsman.
4. No Ombudsman who is assigned or acts as an official representative of his or her agency in
the presentation of papers, talks, demonstrations, or making appearances shall solicit or
accept fees, honoraria, or reimbursement of expenses for personal gain. Any fees or
honoraria offered in connection with the above stated activities shall be paid to the agency.
5. Ombudsman must be alert to anything which will impair their ability to objectively investigate
complaints. The Ombudsman must avoid conflict of interest in the establishment of personal
relationships which may affect impartiality on the job.
6. An Ombudsman may be involved in serving as officer or board member of a social, fraternal,
or religious organization for which the Ombudsman receives no compensation or anything of
value, as long as the organization is not affected by exercise of the Ombudsman’s discretion.
Disclosure of Information
General Information
7. No Ombudsman may use or disclose information gained in the course of, or by reason of, the
Ombudsman’s official position or activities in any way without the express consent of the
resident or complainant.
8. An Ombudsman shall disclose all past appointments, involvement, membership, or interest
that may affect or could reasonably be expected to affect the Ombudsman’s ability to
investigate and resolve complaints in an objective and independent manner.
Nepotism
General Information
9. No Ombudsman shall effectively recommend or decide to hire or promote another person
02OM005E
12/14/2021
Page 1 of 2
Long-Term Care Ombudsman Program
Conflict of Interest Statement and Ethical Guidelines for Supervisors and Volunteers
General Information
General Information
The Older Americans Act Amendments of 1987 requires assurances that there is no conflict of
interest within the Ombudsman Program. Our mandate is to establish mechanisms to identify and
remedy any such conflict. To this end we ask that you study this document and sign it if you are
able to provide the following assurance and meet the following ethical guidelines:
1. No Ombudsman or member of the Ombudsman’s immediate family may own, operate, control,
or have interest, voting rights, or outstanding indebtedness to or be employed by any
company or facility or individual investigated by the Ombudsman.
2. No Ombudsman can serve as an Ombudsman in the Planning and Service area in which they
have been employed by a long-term care facility in the previous twelve months.
3. No Ombudsman may solicit or accept from any person or organization directly or indirectly,
money or anything of value if it could reasonably be expected to influence such Ombudsman’s
official actions or judgment or could reasonably be considered as a reward for any official
action or omission on the part of the Ombudsman.
4. No Ombudsman who is assigned or acts as an official representative of his or her agency in
the presentation of papers, talks, demonstrations, or making appearances shall solicit or
accept fees, honoraria, or reimbursement of expenses for personal gain. Any fees or
honoraria offered in connection with the above stated activities shall be paid to the agency.
5. Ombudsman must be alert to anything which will impair their ability to objectively investigate
complaints. The Ombudsman must avoid conflict of interest in the establishment of personal
relationships which may affect impartiality on the job.
6. An Ombudsman may be involved in serving as officer or board member of a social, fraternal,
or religious organization for which the Ombudsman receives no compensation or anything of
value, as long as the organization is not affected by exercise of the Ombudsman’s discretion.
Disclosure of Information
General Information
7. No Ombudsman may use or disclose information gained in the course of, or by reason of, the
Ombudsman’s official position or activities in any way without the express consent of the
resident or complainant.
8. An Ombudsman shall disclose all past appointments, involvement, membership, or interest
that may affect or could reasonably be expected to affect the Ombudsman’s ability to
investigate and resolve complaints in an objective and independent manner.
Nepotism
General Information
9. No Ombudsman shall effectively recommend or decide to hire or promote another person
02OM005E
12/14/2021
Page 1 of 2
who is a member of the Ombudsman’s immediate family.
10. No Ombudsman who has an immediate family member, as defined in federal rules, can be
designated as an Ombudsman in the facility in which their immediate family member resides.
Public Trust
General Information
11. Business shall not be conducted in restaurants or other public places where a public observer
might reasonably conclude that confidences may be breached due to lack of privacy.
Signature
General Information
I understand that I must uphold the ethical principles outlined above, and I affirm that I am free from
any conflict of interest.
Ombudsman staff
Volunteer
Signature of
Date
Conflict of interest has been identified for the following individual(s):
02OM005E
12/14/2021
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