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Who We Are
Community Education
Our Impact & Financial Health
Give Now
Pro Seniors New Professionals
Employment
Seniors Who Rock
Staff & Leadership
Volunteering
Calendar of Events
News
Legal Services
Join HRAP (Helpline Referral Attorney Panel)
Legal Helpline
Mid-America Pension Rights Project
Veterans Legal Assistance
Ombudsman
Home Options – How to Select
MyCare Ombudsman
Join Voices for Change
Become a Volunteer Ombudsman
Current Ombudsman Volunteers
Family Councils Need You
Senior Medicare Patrol
About SMP
Learn More
Become A Fraud Fighter
Report Fraud
Contact Us
Resources
Elder Financial Exploitation
Financial Exploitation Prevention Project
Legal Toolkits
Medicare-Medicaid Eligibility
Mid-America Pension Rights Project
Fact Sheets
Ohio Legal Help
U.S. Senior Legal Hotline Directory
Contact
Give Now
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)
MM slash DD slash YYYY
Name of Provider
(Required)
Type of Provider
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 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:
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
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