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Are you a...
 
Long-term care resident
 
Family/friend of resident
 
Legal guardian of resident
 
Other
 
 
 
 
How did you hear about the Ombudsman program?
 
Facility staff
 
Ombudsman poster
 
Ombudsman visit
 
Word of mouth
 
Agency referral
 
Other
 

 
 
 
Yes No Not Sure
Was your request responded to in a timely manner?
Was the program representative knowledgeable?
Was your request handled in a professional manner?
Do you feel that your privacy was respected?
Will you call Ombudsman if you need help again?
 
 
 
Are you satisfied with the results to your complaint?
 
Very Satisfied
 
Satisfied
 
Dissatisfied
 
 
 
If you will not let Ombudsman help you again, WHY?
   
 
 
 
How can we improve the Ombudsman program?
   
 
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