Volunteer Ombudsman's Name (required)
Volunteer Ombudsman's Email (required)
Date of Activity (required) MM/DD/YY
Name of Provider (required)
Type of Provider (required)
Nursing Home (NH)Assisted Living (RCF)Group Home (RF2)
Activity Description:
Onsite visit with Residents (including outdoor, window, indoor visits)Virtual visit with residents (Facetime, Zoom, etc.)Resident Council MeetingTelephone Calls to Family/Guardian or ResidentsCase Work, as assigned by a staff ombudsmanContact made with the ProviderOther (specify)
If Other Activity, please specify
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 (required)
Male Residents:
Female Residents:
Total Residents:
If telephone calls, total number of calls made including leaving a voice mail, disconnected, no answer, wrong number and completed conversations:
If you attended a Resident Council meeting, the number of residents attending the meeting?
Male Attendees:
Female Attendees:
Total Attendees:
If activity related to a cases, what is the 4-digit case number (provided by the staff ombudsman)?
What did you notice during your visit? What did the residents tell you? How did you educate, empower, or advocate? (required)(please use hyphens for bullet points)
By checking this box, I affirm that the information contained in this report is true and accurate, to the best of my knowledge.
