We help seniors resolve legal & long-term care problems

Ombudsman Volunteer Report

Step 1: Fill in the boxes below after each visit to a facility.

Volunteer Ombudsman's Name (required)

Volunteer Ombudsman's Email (required)

Type of Facility (required)
Nursing HomeRCF (assisted living)

Name of Facility (required)

Date Of Facility Visit (required) MM/DD/YY

How many minutes were spent traveling to/from the facility (round trip) (required)

How many miles were traveled to/from the facility (round trip) (required)

Time you arrived at the facility for your visit (required)

Time you left the facility after your visit (required)

Number of residents you had contact with (required)
Male Residents:
Female Residents:
Total Residents:

If you attended a Resident Council meeting:

The total minutes spent with Resident Council

The number of residents attending the meeting

I called the following staff Ombudsman about today's activity: (required)

I need the following materials: (required)
NoneResident Rights PamphletsBusiness CardsCrime Victim Rights / Assistance MaterialsOther
If "Other" please specify:

Delivery of materials: (required)
NoneMail the materials to meI will arrange to pick the materials up at Pro Seniors

Is this visit related to a case?
If yes, what is the case number:

Our LTC Ombudsman Role is to recognize concerns and to advocate for the rights of residents. As the advocate for residents in this home, what did you notice during your visit? What did the residents tell you?(required)

What did the Ombudsman staff ask you to do during your visit? (required)

How did you work on these issues today? (required)

Number of minutes to complete this report (required)

Step 2: 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)

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