OMB Complaint Documentation 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. Question Title * 1. Ombudsman Name Name Email Address Question Title * 2. Intake Date Date / Time Date Time AM/PM - AM PM Question Title * 3. First Action Date Date / Time Date Question Title * 4. Close Date Date / Time Date Time AM/PM - AM PM 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. Question Title * 5. Intake Summary Question Title * 6. Anonymity Required Yes No Question Title * 7. Consent Obtained to Work on Resident's Behalf Yes No Question Title * 8. Consent to Review Records Yes No If yes, Oral or Written 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. Question Title * 9. Complaint Role Question Title * 10. Complainant Complainant Name Complainant Role Agency/Company Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Work Phone Number Cell Phone Number Home Phone Number 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. Question Title * 11. Facility Type SNF ICF RCF ALF Question Title * 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. Question Title * 13. Resident Name Question Title * 14. Legally Authorized Representative? Yes No If yes, Name? Next
