• Ombudsman: Name of the Volunteer Ombudsman.
  • Intake Date: Date the Ombudsman Program was made aware of the complaint.
  • First Action Date: Date the Ombudsman completed the first case action, i.e. investigation, interviews.
  • Close Date: Date the complaint was closed.

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* 1. Ombudsman Name

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* 2. Intake Date

Date / Time

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* 3. First Action Date

Date / Time

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* 4. Close Date

Date / Time
  • Intake Summary: Summary of the initial contact regarding the complaint.
  • Anonymity Requested: Check “Yes” if the resident/resident representative requests the resident be anonymous. Or check “No” if the resident/resident representative gives permission to disclose the resident’s identity.
  • Consent Obtained to Work on the Resident’s Behalf: Check “Yes” if the resident/resident representative gives permission for the Ombudsman to work on the complaint on the Resident’s behalf. Or check “No” if the resident/resident representative does not give permission for the Ombudsman to work on the complaint on the Resident’s behalf.
  • Consent to Review Records: Check “Yes” if the resident/resident representative gives permission for the Ombudsman to review records. If yes, was the consent given orally or by written consent and check the appropriate box.

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* 5. Intake Summary

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* 6. Anonymity Required

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* 7. Consent Obtained to Work on Resident's Behalf

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* 8. Consent to Review Records

  • Complainant Role: resident, resident representative, family, etc.
  • Complainant Name: Name of the individual providing the complaint information.
  • Agency/Company: If the Complainant works for an agency/company, list the name of the agency/company.
  • Address: Address of the Complainant.
  • Home Phone No.: List the home telephone number for the complainant including area code.
  • Work Phone No.: List the work telephone number for the complainant including area code.
  • Cell Phone No.: List the cellular telephone number for the complainant including area code.

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* 9. Complaint Role

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* 10. Complainant

  • Facility Type: Check the appropriate box for either Skilled Nursing Facility/Intermediate Care Facility (SNF/ICF) or the box for Residential Care Facility/Assisted Living Facility (RCF/ALF).
  • Facility Name: List the name of the facility the resident resides.

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* 11. Facility Type

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* 12. Facility Name

  • Resident Name: List the name of the resident
  • Legally Authorized Representative: Check ‘Yes” if the resident has a legally authorized representative. Check “No” if the resident does not have a legally authorized representative. If Yes, Name: List the name of the legally authorized representative.

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* 13. Resident Name

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* 14. Legally Authorized Representative?

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