Phone: (513) 345-4160
Volunteer Ombudsman's Name (required)
Volunteer Ombudsman's Email (required)
Date of Activity (required) MM/DD/YY
Name of Provider (required)
Type of Provider (required)
Nursing Home (NH)Assisted Living (RCF)Group Home (RF2)
Onsite visit with Residents (including outdoor, window, indoor visits)Virtual visit with residents (Facetime, Zoom, etc.)Resident Council MeetingTelephone Calls to Family/Guardian or ResidentsCase Work, as assigned by a staff ombudsmanContact made with the ProviderOther (specify)
If Other Activity, please specify
How many minutes were spent traveling to/from the facility (round trip) (required)
How much time was spent on this activity (including preparation, the activity itself, and time spent writing the report, and excluding travel time)
Number of residents or family/guardian you had contact or conversation with (required)
If telephone calls, total number of calls made including leaving a voice mail, disconnected, no answer, wrong number and completed conversations:
If you attended a Resident Council meeting, the number of residents attending the meeting?
If activity related to a cases, what is the 4-digit case number (provided by the staff ombudsman)?
What did you notice during your visit? What did the residents tell you? How did you educate, empower, or advocate? (required)(please use hyphens for bullet points)
By signing below you are affirming that the information in this report is true and accurate to the best of your knowledge.
(Please sign by drawing your signature with your computer mouse or finger on your phone or tablet)
Pro Seniors, Inc.7162 Reading Road, Suite 1150 Cincinnati, OH 45237
Toll Free/TDD: (800) 488-6070
Local: (513) 345-4160