Phone: (513) 345-4160
Volunteer Ombudsman's Name (required)
Volunteer Ombudsman's Email (required)
Date of phone calls (required) MM/DD/YY
Name of Facility (required)
What type of facility is this?
Calls made to (check one)
Family Census ListResident Census List
Time spent making calls (including conversations, voice mail, disconnected/wrong numbers, writing reports, calling an ombudsman for advice or clarification, etc.): (required)
Number of calls leaving voice mail message:
Number of calls reaching & speaking with family/guardian:
Number of Family Members or Residents reached: (required)
Scan, or take a photo, of each Checklist.
Email family Checklist for each conversation to: firstname.lastname@example.org
Or, mail a hard copies of Family Checklist to:
Attn: Volunteer Coordinator
7162 Reading Road, Suite 1150
Cincinnati, OH 45237
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.
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Pro Seniors, Inc.7162 Reading Road, Suite 1150 Cincinnati, OH 45237
Toll Free/TDD: (800) 488-6070
Local: (513) 345-4160