Volunteer Intake

Thank you for volunteering with Multnomah County. This form collects information on your potential or actual conflicts of interest in your role with Multnomah County and asks you to review and acknowledge relevant policies. Personal information will be held in confidence as allowed by law.

If there is any change to your potential or actual conflicts of interest during your volunteer term, please complete a new form.

If you have any questions, please contact the Office of Community Involvement at community.involvement@multco.us or 503-988-3450.

First Name

Last Name

Phone

Employer

If you are a student, retired, or unemployed, you can provide that information under Employer.

Occupation

Is your role as a member of this advisory board or committee your sole position with the county?

YesNoE.g. Serving on another advisory board or committee for Multnomah County, volunteering for a department

What are your other roles with Multnomah County

Do you have any relationships outside of your county volunteer position with local service providers/contractors?

YesNoEg. You are an employee or board member of a non-profit that receives funding from Multnomah County

Please describe the relationship and your responsibilities (eg. board member, employee, volunteer)

State any action/decision/vote/debate/recommendation that you make in your work for the county that may result in financial gain or detriment to you that may be afftected by outside relationships:

Disclose any actual or potential conflict of interest you may have arising from the situation described above or from any other situation

Do you have any relatives, spouses, domestic partners or persons with who you have an intimate relationship for whom you have been asked to participate in personnel action?

YesNoEg. Your spouse or close relative is employed by Multnomah County

Identify those persons you have an intimate relationship and for whom you have been asked to participate in a personnel action:

Review of Policies

I have reviewed the following Multnomah County Personnel Rules - 3-20: Political Activity, 3-30: Code of Ethics, 3-40: Discrimination and Harassment Free Workplace, 3-42: Gender Identity and Gender Expression Harassment and Discrimination-Free Workplace, 3-47: Maintaining a Professional and Respectful Workplace, 3-60: Discipline and Dismissal

I have reviewed the state of Oregon’s ethics manual, “A Guide for Public Officials”

I have disclosed on this form any potential or actual conflicts of interest to the best of my knowledge.

Signature

Please type your full name as your signature

Date

Contact Information