Ombudsman Associate
Advocacy Visit Form

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

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* Name of Ombudsman Associate:

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* 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.

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* This is my first Visit to this location?

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* I visit this Facility
Tell us How Often

Weekly

Biweekly

Monthly

Quarterly

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* Date of My Visit

Date / Time

Date

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* Did you review or receive any information about the Facility prior to your visit?
If yes, please write what information you reviewed.

Yes

Pre-Advocacy Work

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* Time spent reviewing information:
Remember, this counts towards your activity time!

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

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

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* Was this visit related to a case?

Yes

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

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* Number of Male Residents Visited:

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* Number of Female Residents Visited:

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* The First Resident I met with was.
Name

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* Gender

Male

Female

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* During my visit we talked about.... *
What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

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* 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).*

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

Yes

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* The next resident I met with was...

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* Gender

Male

Female

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* During my visit we talked about.... *
What did the residents say? Make sure to 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).

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

Yes

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* The next resident I met with was...

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* Gender

Male

Female

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* During my visit we talked about....
What did the residents say? Make sure to 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.

Yes

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* The next resident I met with was...

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* Gender

Male

Female

Question Title

* During my visit we talked about....
What did the residents say? Make sure to 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.

Yes

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* The next resident I met with was...

Question Title

* Gender

Male

Female

Question Title

* During my visit we talked about....
What did the residents say? Make sure to 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.

Yes

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* Name of Ombudsman Associate:

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* 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.

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* This is my first Visit to this location?

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* I visit this FacilityTell us How Often

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* Date of My Visit

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* Did you review or receive any information about the Facility prior to your visit? If yes, please write what information you reviewed.

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* Time spent reviewing information:Remember, this counts towards your activity time!

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

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

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* Was this visit related to a case?

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

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* Number of Male Residents Visited:

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* Number of Female Residents Visited:

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* The First Resident I met with was.Name

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* Gender

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* During my visit we talked about.... *What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

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* 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

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* During my visit we talked about.... *What did the residents say? Make sure to 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.... What did the residents say? Make sure to 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.... What did the residents say? Make sure to 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.... What did the residents say? Make sure to 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.

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

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

* 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.

* I visit this Facility
Tell us How Often

* Did you review or receive any information about the Facility prior to your visit?
If yes, please write what information you reviewed.

* Time spent reviewing information:
Remember, this counts towards your activity time!

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

* The First Resident I met with was.
Name

* During my visit we talked about.... *
What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

* 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).*

* During my visit we talked about.... *
What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

* 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).

* During my visit we talked about....
What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

* 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).

* During my visit we talked about....
What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

* 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).

* During my visit we talked about....
What did the residents say? Make sure to ask open-ended questions about all aspects of life at the facility.

* 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).

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