Fill in and submit this report for each day you have spent time on a volunteer activity. Submit no later than 6 days from the time the activity occurred.

Volunteer Ombudsman's Name(Required)

Volunteer Ombudsman's Email(Required)

Date of Acrtivity(Required)

Name of Provider(Required)

Type of Provider

Nursing Home (NH)

Assisted Living (RCF)

Group Home (RF2)

Activity Description (Please Choose All that Apply)(Required)

Onsite visit with Residents (including outdoor, window, etc.)

Virtual visit with residents (Facetime, Zoom, etc.)

Resident Council Meeting

Telephone Calls to Family/Guardian or Residents

Case Work, as assigned by a staff ombudsman

Contact made with the Provider

Other

If Other, please specify(Required)

How many minutes were spent traveling to/from the facility (round trip)(Required)

How much time was spent on this activity (including preparation, the activity itself, and time spent writing the report, and excluding travel time)

Number of residents or family/guardian you had contact or conversation with

Male Residents:(Required)

Female Residents:(Required)

Isolated Residents (Please reference who in the notes section below):(Required)

Total Residents:(Required)

If telephone calls, total number of calls made including leaving a voice mail, disconnected, no answer, wrong number, and completed conversations:

Male Attendees(Required)

Female Attendees:(Required)

Total Attendees:(Required)

If activity is related to a case, what is the 4-digit case number (provided by the staff ombudsman)?

Prep Work & Isolated Resident Screening

What information did you review prior and at facility?

(Please indicate past reports, cases, survey and website lookup, TA from other Ombudsman, collected census, new residents, collected RC meeting notes, and grievances.)

Screening Isolated Residents(Required)

(Please note in interview portion who these are and how you identified them. See staff and RCP to identify isolated resident(s))

Observations, Interviews, Names, and Room Numbers

What did you notice during your visit? What did the residents tell you? How did you educate, empower, or advocate? (please use hyphens for bullet points)(Required)

Call lights within reach of resident & answered; cleanliness and odors of facility and residents; Staff interactions; water readily available; any meals in progress; noise level comfortable/home like environment; activities are posted, appropriate, and occurring; Ombudsman sign, Rights, weekly menu, and staffing posted.

Follow Up, Resolutions with Staff, and Next Steps(Required)

Note all follow-ups with residents and staff. (close the loop). Attach or send in consent forms if applicable including pics of postings or any pertinent information.

If there are additional files to submit, attach in an email and send to ovol@proseniors.org. Click on the 'Submit' button below to submit your Ombudsman Volunteer Report to Pro Senios

BY CHECKING THIS BOX, I AFFIRM THAT THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND ACCURATE, TO THE BEST OF MY KNOWLEDGE.(Required)

Affirm

Ombudsman Volunteer Report Draft

Prep Work & Isolated Resident Screening

Observations, Interviews, Names, and Room Numbers