Please Note: A criminal background check will be completed on each applicant.

Contact in Emergency:


I. Skills and Interests

1. Volunteer Experience:

2. Interests, Special Skills, Hobbies:

3. Work Experience:

4. Education Background:

5. Current Occupation:

6. Have you ever been convicted of a crime:

7. Why do you want to be a Volunteer Ombudsman?

8. Is there a group with whom you are particularly interested in working? (check all that apply):
People with mental disability
People with Alzheimer's/dementia

9. Is there any group you would not feel comfortable working with?
Yes (which groups):

10. What kind of volunteer work interests you? We provide the training and supervision. (check all that apply) You can change your choices at any time.
Observe for Advocacy: Be assigned to make regular visits to residents in a long-term care facility.
Monitoring visits: Visit a number of facilities in your area.
Complaint Investigation: We will train Volunteer Ombudsmen to do complex complaint investigations. When the Ombudsman office receives a complaint, the Volunteer will go to the facility to gather information by talking to the residents, and staff. With LTCOP supervision, the Volunteer will work toward resolution of the problem.
Be a Resident Rights Educator: Lead a group presentation on the rights of residents for facility staff, family members, or residents. We provide all needed material and help you prepare for the presentation.
Contact home care consumers who are on a waiting list to receive Independent Support Services (homemaker services) to find out how they are getting by, provide information and referral and discuss whether their needs have changed.
Be an advocate in your community. We are training bilingual individuals to reach out to the elderly and people with disabilities who need assistance in resolving problems around the quality of, and access to long-term care services. We are looking for volunteers to work within Maine's growing ethnic and minority communities.The volunteer will help the Ombudsman staff to understand cultural differences and assist the home care consumer to have a better understanding of the questions being asked through the interpreter as well as providing a comfort level for the consumer.

II. Availability

11. Will you be able to attend quarterly meetings? We ask all Volunteer Ombudsman to attend a minimum of two quarterly meetings/trainings each year. We schedule enough trainings throughout the state so that you can choose the sessions you want to attend.

12. Will you be able to spend a minimum of 4 hours a month on your Ombudsman duties?

13. Will you be able to keep simple records and complete regular reports to our office about your Ombudsman work? We provide a form for you to use.

14. Do you have available transportation? You will need this to complete your Ombudsman work, visiting residents and attending trainings.

You will need to submit a copy of your auto "insurance card" for our records. Our office must have a copy of this to complete your application.

III. References

15. How did you hear about our program?

16. List the names and phone numbers of two personal references (not a relative, Please):


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By submitting this application, you agree to accept the following terms:
(1) A volunteer must be over the age of 18.
(2) The information on this form is true, accurate and complete to the best of the applicant’s knowledge.
(3) Withholding or giving false information will be sufficient cause for cancellation of this application and/or separation of service from the Ombudsman Program.
(4) A criminal background check will be completed for every applicant.
(5) A copy of the applicant’s Conflict of Interest form and auto insurance card must be submitted to the Ombudsman Program.
(6) I understand that after I submit my application, it will be reviewed and my eligibility for volunteer work will be determined.
I agree to the terms above.



"All long-term care consumers have the right to be treated with dignity and respect."