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Complete this short survey about family councils to share your experiences with the State Long-Term Care Ombudsman. Questions with an asterisk are required. We appreciate your willingness to share your stories.

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* 1. First Name [Optional]

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* 2. Last Name [Optional]

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* 3. County of Residence [Required]

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* 4. County that Long-Term Care Facility is Located In [Required]

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* 5. Will you be attending the State Long-Term Care Ombudsman Family Forum?

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* 6. How would you like to receive additional information about the State Long-Term Care Ombudsman Family Forum? [Optional]

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* 7. Is there a family council at your loved one's long-term care facility?

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* 8. Are you involved in a family council?

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* 9. If you are involved in a family council, do you find it helpful in advocating for your loved one's care?

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* 10. If you are involved in a family council, how did you meet during COVID?

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* 11. Are you interested in starting a family council?

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* 12. What topics are discussed during family council meetings?

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* 13. If you participate in a family council, does the facility listen to your views and act upon the grievances presented?

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* 14. What topics would you most like to learn about or discuss at the State Long-Term Care Ombudsman Family Forum?

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* 15. Are there any questions you would like to be addressed at the State Long-Term Care Ombudsman Family Forum?

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* 16. Is there anything else you would like to add?

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