OMBUDSMAN MONTHLY REPORT INSTRUCTIONS FOR COMPLETION

Date of Visit or Phone Call: Enter the date of visit to the facility or date of a phone call made to you/from you.

Round Trip Miles: Enter the total number of miles for one round trip visit to facility.

Length of Visit in Hours: Round all visits to the nearest hour.

Number of Resident Contacts: Enter the number of residents that were spoken with in your capacity as an Ombudsman.

Number of Family/Other Contacts: Enter the number of family members or others that you spoke with that day in the capacity as an Ombudsman.

Attendance at Family (F) or Resident (R) Council Mtg.: Enter an "F" to indicate that you attended a Family Council meeting, enter an "R" to indicate that you attended a Resident Council meeting.

Conducted Inservice R/F/S (topic): If you conducted an inservice, please enter an "R" to indicate it was an inservice for residents, an "F" to indicate for family members, an "S" to indicate for staff Circle multiple letters if appropriate. Next to the appropriate letter(s) please enter the topic.

Attended Inservice R/F/S: If you attended an inservice, please enter an "R" to indicate it was an inservice for residents, an "F" to indicate family, an "S" to indicate for staff. Circle multiple letters if appropriate. Next to the appropriate letter(s) please enter the topic.

Consultation with Facility Staff (topic): Please indicate the topic of the consultation.

Survey Attended/Number of Residents: Please indicate the number of residents at the survey meeting.

Requests for Information and Assistance: Please indicate the topic of information or assistance needed from the AAA.

Totals: Please total all columns that have a value in them.

How may we help you? Please use this space if you have questions or comments.

Please send me these forms/brochures/Outreach Materials: Please indicate the number of each item needed.