Fill in and submit this report for each day you have spent time on a volunteer activity.
Submit no later than 6 days from the time the activity occurred.
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)
Activity (check one)
How many minutes were spent traveling to/from the provider location (round trip or N/A)
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 Family Members or Residents reached: (required)
If telephone calls, total number of calls made including leaving a voice mail, disconnected, answer, wrong number, and completed conversations:
If resident council meeting, the number of residents attending the meeting?
If activity related to a case, what is the 4-digit case number (provided by the staff ombudsman)?
As the advocate for residents in this home, what did you notice during your visit? What did the residents tell you? How did you educate, empower, or advocate? (required)(please use "-" for bullet point format)
If there are additional files to submit, attach in email and send to firstname.lastname@example.org
Click on the button below to submit your Ombudsman Volunteer Report
to Pro Seniors.
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)
Questions? Leave a voice mail message at 513-458-5520, or call the ombudsman helpline at 513-458-5518.