Form Title |
Form # |
|
A Guide for the “Mandated” Reporter |
0025 |
|
Activity Report Log |
0067 |
|
Affidavit of Insurance |
0008 |
|
Agency/Volunteer Agreement |
0062 |
|
Assistance Survey |
0019 |
|
Authorization of Complainant to Reveal Identity |
0016 |
|
Authorization of Representative & Consent for Release of Information |
0013 |
|
Authorization to Release Confidential Information |
0014 |
|
Authorization to Reveal Identity |
0011 |
|
Certification of New Ombudsman |
0005 |
|
Client & Community Satisfaction Survey |
0015 |
|
Combination Authorization to Release Medical Records/Confidentiality/Identity |
0042 |
|
Community Activity Report Long |
0068 |
|
Complaint from Long-Term Care Ombudsman |
CDA 223 |
|
Confidentiality Statement of Paid Ombudsman Program Staff |
0033 |
|
Conflict of Interest Statement |
0041 |
|
Consumer/Resident Satisfaction Survey |
0029 |
|
Drug Free Work Place Certification |
0064 |
|
Durable Power of Attorney for Health Care (DPACH) |
0021 |
|
Employee Statement (Elder or Dependent Abuse Reporting) |
0004 |
|
Facility Coverage Format |
0036 |
|
Focus Visit Report |
0066 |
|
Indicators of Abuse |
0031 |
|
Indicators of Abuse (Spanish) |
0032 |
|
Letter to Place Ombudsman Poster in Facility |
0035 |
|
New Program Coordinator Agreement with the OSLTCO |
0010 |
|
News Release |
0006 |
|
News Release Format |
0037 |
|
NORS Case Specific Information (Sample 1) |
0043 |
|
NORS Categories (COSAT) (Sample 1) |
0070 |
|
NORS Categories (Sample 2) |
0071 |
|
NORS Categories (Sample 3) |
0072 |
|
NORS Complaint Specific Information (Sample 2) |
0044 |
|
NORS Complaint Specific Information (Sample 3) |
0045 |
|
Ombudsman Code of Ethics |
0038 |
|
Ombudsman Mileage Expense Report |
0020 |
|
Ombudsman Progress Notes |
0017 |
|
Ombudsman Telephone Log |
0018 |
|
Permission to Photograph & Use or Reproduce Photos |
0028 |
|
Pledge of Confidentiality for Ombudsman Trainees |
0039 |
|
Position Description for Administrative Coordinator |
0054 |
|
Position Description for Board Members |
0059 |
|
Position Description for Board Officers |
0058 |
|
Position Description for Executive Director (Sample 1) |
0052 |
|
Position Description for Executive Director/Program Coordinator/Manager (Sample 2) |
0057 |
|
|
|
|
Position Description for Resource Coordinator |
0051 |
|
Position Description for Volunteer |
0053 |
|
Position Description for Volunteer Coordinator |
0050 |
|
Presentation Summary (Training, Community Education, etc.) |
0030 |
|
Press Release |
0034 |
|
Prospective Board Member Application/Information |
0063 |
|
Registration of Witnesses for Durable Power of Attorney for Health Care (DPAHC) |
0040 |
|
Renewal of Ombudsman Certification (Memo) |
0007 |
|
Residential Care Facility for the Elderly (RCFE) Checklist (Sample 1) |
0060 |
|
Residential Care Facility for the Elderly (RCFE) Checklist (Sample 2) |
0061 |
|
Residents’ Rights in a SNF |
0027 |
|
Residents’ Rights in a SNF (OBRA) |
0074 |
|
Residents’ Rights in an RCFE |
0026 |
|
Residents’ Rights in an RCFE (OBRA) |
0073 |
|
Skilled Nursing Facility (SNF) Checklist (Sample 1) |
0046 |
|
Skilled Nursing Facility (SNF) Checklist (Sample 2) |
0048 |
|
Skilled Nursing Facility (SNF) Intake On-Site Visit Checklist |
0049 |
|
Statement of Confidentiality |
0075 |
|
Statement of Obligation to Protect Confidential Information |
0012 |
|
Telephone Accessibility Notice |
0003 |
