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: YesNo

Verbal Consent to Reveal Identity: YesNo

Resident Consent

Verbal Consent to Investigate: YesNo

Verbal Consent to Reveal Identity: YesNo

Complaint as presented by the complainant or resident.



Who presented the above complaint? ComplainantResident

Prior actions taken by complainant or resident to resolve complaint.



Who took prior the prior actions? ComplainantResident

Desired outcome as presented by complainant or resident.



Who presented the desired outcome? ComplainantResident

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