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Ohio Department of Aging Ombudsman Associate Program - Application Form

Ombudsman: Expect Excellence in your Care

To give your time as a volunteer ombudsman associate, please complete the application below. Your information will be forwarded to the regional program serving your community.

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):










Please refer to our Privacy Statement for details about information sent electronically.