We help seniors resolve legal & long-term care problems

Ombudsman Volunteer Report

Family or Resident Telephone Call Report



Instructions

  • Fill out a Family/Resident Information Collection report for each conversation (sent via email)
  • Fill out this report for each day you make phone calls.

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)

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)
Male:
Female:

Scan, or take a photo, of each Checklist.

Email family Checklist for each conversation to: ombudvol@proseniors.org

Or, mail a hard copies of Family Checklist to:

Pro Seniors

Attn: Volunteer Coordinator

7162 Reading Road, Suite 1150

Cincinnati, OH 45237



Additional comments:

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.

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