NAME:
FOR THE MONTH OF:
FACILITY VISITED
1. DATE OF VISITTIME OF VISITHOURS IN FACILITY
2. DATE OF VISITTIME OF VISITHOURS IN FACILITY
3. DATE OF VISITTIME OF VISITHOURS IN FACILITY
4. DATE OF VISITTIME OF VISITHOURS IN FACILITY
5. DATE OF VISITTIME OF VISITHOURS IN FACILITY
6. DATE OF VISITTIME OF VISITHOURS IN FACILITY
TOTAL VISITS:
TOTAL HOURS:
MILES TO FACILITY (Round Trip):X NUMBER OF TRIPS THIS MONTH= TOTAL MILES.NUMBER OF RESIDENTS CONTACTED:
NUMBER OF FAMILY CONTACTED:
Complaint Types (Enter from list below)
| A | Resident | F | AAA Info & Assistance |
| B | Relative/Friend | G | Other Social Service Agency |
C | Non-Relative Guardian/
Legal Rep. | H | Other Medical: Physician/Staff of Hospitals,
Hospices, clinics, etc. |
D | Ombudsman | I | Unknown/Anonymous |
E | Facility | J | Other |
COMPLAINTS/CONCERN
ACTION TAKEN
NUMBER OF CONSULTATIONS WITH STAFF:
TOPICS DISCUSSED WITH STAFF
TRAINING GIVEN TO STAFF:(enter Y/N)
1a. DATETIME
TOPIC# OF STAFF ATTENDED
2a. DATETIME
TOPIC# OF STAFF ATTENDED
3a. DATETIME
TOPIC# OF STAFF ATTENDED
ATTENDED, OR PROVIDED TRAINING TO FAMILY/RESIDENT COUNCILS: (Enter Y/N)
1b. DATETIME
OCCASION# OF FAMILY# OF RESIDENTS
2b. DATETIME
OCCASION# OF FAMILY# OF RESIDENTS
3b. DATETIME
OCCASION# OF FAMILY# OF RESIDENTS
PRESENTATIONS/OUTREACH ABOUT OMBUDSMAN PROGRAM: (Enter Y/N)
1c. DATETIME
TOPIC# OF PEOPLE ATTENDED
2c. DATETIME
TOPIC# OF PEOPLE ATTENDED
3c. DATETIME
TOPIC# OF PEOPLE ATTENDED
HOW MAY WE HELP YOU?
Please send me these forms/brochures/Outreach Materials: (Select one or more of the following)
| Clicking the "SEND IT" button will email this form (if allowed by browser) to Harry Comer, Regional Ombudsman,
additionally a copy will be returned to you. |
| Select Either of These Two Buttons
|
