Report your resident interviews at a nursing home, assisted living, or adult care facility. You should try to meet with at least five residents per visit. If you met with more, you may complete an additional form. Quality of the interviews versus quantity is desired. If you received a complaint during the visit, complete the intake form and notify the Regional Program at 614-345-9198 or 800-536-5891

Question Title

* Name of Ombudsman Associate:

Question Title

* Facility Name:
*Please complete separate reports for each facility type when located on the same campus, i.e. a health care center and assisted living at a continuing care retirement community.

Question Title

* This is my first Visit to this location?

Question Title

* I visit this Facility
Tell us How Often

Question Title

* Date of My Visit

Date

Question Title

* Did you review or receive any information about the Facility prior to your visit? 
If yes, please write what information you reviewed and how long did you review the information. This is added to your time as a volunteer! 

Question Title

* The length of time I spent at the facility visiting residents.

Question Title

* The time it took me to travel to the facility and back.

Question Title

* Was this visit related to a case? 

Question Title

* While at the Facility what were you sensory observations?
What did you see, smell, hear be detailed.

Question Title

* Number of Male Residents Visited:

Question Title

* Number of Female Residents Visited:

Question Title

* The First Resident I met with was.
Name

Question Title

* Gender
 

Question Title

* During my visit we talked about.... *
Ask open-ended questions about all aspects of life at the facility.

Question Title

* During our conversation, the resident voiced a concern. 
*If yes, please obtain written consent from resident and complete intake form or call the intake line (614-345-9198).

Question Title

* I educated the resident on the role and scope of the Long-term Care Ombudsman Program; and left information pertaining to resident rights.

Question Title

* The next resident I met with was...

Question Title

* Gender

Question Title

* During my visit we talked about.... *
Ask open-ended questions about all aspects of life at the facility. 

Question Title

* During our conversation, the resident voiced a concern.
*If yes, please obtain written consent from resident and complete intake form or call the intake line (614-345-9198). 

Question Title

* I educated the resident on the role and scope of the Long-term Care Ombudsman Program; and left information pertaining to resident rights.

Question Title

* The next resident I met with was...

Question Title

* Gender

Question Title

* During my visit we talked about....
Ask open-ended questions about all aspects of life at the facility.

Question Title

* During our conversation, the resident voiced a concern.
*If yes, please obtain written consent from resident and complete intake form or call the intake line (614-345-9198).

Question Title

* I educated the resident on the role and scope of the Long-term Care Ombudsman Program; and left information pertaining to resident rights.

Question Title

* The next resident I met with was...

Question Title

* Gender

Question Title

* During my visit we talked about....
Ask open-ended questions about all aspects of life at the facility.

Question Title

* During our conversation, the resident voiced a concern.
*If yes, please obtain written consent from resident and complete intake form or call the intake line (614-345-9198).

Question Title

* I educated the resident on the role and scope of the Long-term Care Ombudsman Program; and left information pertaining to resident rights.

Question Title

* The next resident I met with was...

Question Title

* Gender

Question Title

* During my visit we talked about....
Ask open-ended questions about all aspects of life at the facility.

Question Title

* During our conversation, the resident voiced a concern.
*If yes, please obtain written consent from resident and complete intake form or call the intake line (614-345-9198).

Question Title

* I educated the resident on the role and scope of the Long-term Care Ombudsman Program; and left information pertaining to resident rights.

Question Title

* Extra space if you met with more than five residents or other notes.

Question Title

* Do you need any materials or have any questions for the Volunteer Coordinator? 
Materials include business cards, pamphlets, etc. 

Question Title

* Any action steps needed?

T