Volunteer Ombudsman:
E-mail Address:
Date of Activity:
Facility:
(Check One) Nursing Home Residential Care Facility
IF YOU VISIT A FACILITY WITH BOTH A NURSING HOME UNIT AND A RESIDENTIAL CARE UNIT PLEASE USE A SEPARATE CONTACT SHEET FOR EACH UNIT.
Time of Day:
Time Spent in Facility: minutes
Travel Time (to and from): minutes
Time Spent on Paperwork: minutes
(Check all that apply)
Routine visit to assigned facility Resident Council Meeting In-Service Training for Staff Participation in Survey Training/Other Family Council Meeting
OBSERVATION CHECKLIST and ACTION TAKEN
Please list here any follow up actions from a previous visit as well as your comments about how you addressed any problems noted above to the contact person and what action is being taken to change the problem. Use a separate piece of paper if you need more room. NOTE: DO NOT SHARE INFO WITH THE FACILITY WITHOUT THE RESIDENT'S PERMISSION.
Questions for the Volunteer Program Director?
Re-Type Code:
"All long-term care consumers have the right to be treated with dignity and respect."
