Ombudsman Volunteer Report

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

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)

Total Residents:(Required)

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(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)?

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)

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