Form Aaa-1059a Forna - Conflict Of Interest Statement printable pdf download

AAA-1059AFORNA (9-09)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Aging and Adult Services

Long Term Care Ombudsman Program

CONFLICT OF INTEREST STATEMENT

Let it be known to all that neither I nor my immediate family members (spouse, sibling, child

or parent):

• are involved (directly or indirectly) in the licensing or certification of long term care

facilities or a provider of long term care services;

• have ownership or investment interest (represented by equity, debt or other financial

relationship) in a long term care facility or a long term care service;

• are employed by, or participate in the management of a long term care facility;

• receive, or have the right to received (directly or indirectly) remuneration (in cash or

in-kind) under a compensation arrangement with an owner or operator of a long term

care facility;

• receive services from a long term care provider.

If I become involved in a conflict of interest as described in the Ombudsman Program standards

or believe an activity that I am involved with may be conflict, I will take responsibility to advise

my supervisor of such a possible conflict.

A request for Waiver of a Conflict of Interest Statement may be made according to the Long

Term Care Ombudsman Program Policy 3705.4.

PRINT NAME OF OMBUDSMAN OR VOLUNTEER

SIGNATURE OF OMBUDSMAN OR VOLUNTEER

DATE

PRINT NAME OF OMBUDSMAN COORDINATOR

SIGNATURE OF OMBUDSMAN COORDINATOR

DATE

Equal Opportunity Employer/Program  Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI &

VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and

the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services,

activities, or employment based on race, color, religion, sex, national origin, age, and disability. The Department

must make a reasonable accommodation to allow a person with a disability to take part in a program, service or

activity. For example, this means if necessary, the Department must provide sign language interpreters for people

who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department

will take any other reasonable action that allows you to take part in and understand a program or activity,

including making reasonable changes to an activity. If you believe that you will not be able to understand or take

part in a program or activity because of your disability, please let us know of your disability needs in advance if

at all possible. To request this document in alternative format or for further information about this policy, contact

602-542-4446; TTY/TDD Services: 7-1-1.

Form Aaa-1059a Forna - Conflict Of Interest Statement