We help seniors resolve legal & long-term care problems

    OFFICE OF THE STATE LONG-TERM CARE OMBUDSMAN

    VOLUNTEER ASSOCIATE COMPLAINT INTAKE SHEET

    Date Received:

    Volunteer Name:

    Volunteer Email:

    Provider Name:

    Provider Type:[radio* ProviderType use_label_element default:1 "NH" "RCF" "RF2"]

    Complainant (if other than resident)

    Address:

    Phone Number:

    Relationship to Client:

    Resident Contact Information



    Room Number:

    Date of Birth:

    Phone Number:

    Complainant Consent



    Verbal Consent to Investigate:

    Verbal Consent to Reveal Identity:

    Resident Consent



    Verbal Consent to Investigate:

    Verbal Consent to Reveal Identity:

    Complaint as presented by the complainant or resident.



    Who presented the above complaint?

    Prior actions taken by complainant or resident to resolve complaint.



    Who took prior the prior actions?

    Desired outcome as presented by complainant or resident.



    Who presented the desired outcome?

    Action taken by the volunteer (steps taken to investigate and report to appropriate staff):

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