This instrument was developed for the National Board and Care Survey project. This project was conducted by the Bureau of the Census under contract for the Department of Health and Human Services (HHS) Office of Disability, Aging and Long-Term Care Policy. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.
| NOTE: This is a recreation of this form. See the PDF version for a scanned version of the actual form. |
QUESTIONNAIRE 5
LOCAL OMBUDSMAN
| STATE: _________________________ AGENCY: _________________________ CONTACT: _________________________ POSITION: _________________________ | DATE: _________________________ INTERVIEWER: _________________________ |
| START TIME: _________________________ |
1. Does the ombudsman program in this state require visits to board and care homes at regular intervals?
_____ No
_____ Yes
SPECIFY INTERVALS _________________________
2. How many staff does your ombudsman program have who deal with B&C issues?
Enter number of full time equivalent: _____
3. How does your program provide information to the public and others about board and care homes and issues? (CHECK ALL THAT APPLY)
_____A. Making B&C home survey reports available
_____B. Making ombudsman program information available
_____C. Providing training on B&C regulations and problems
_____D. Providing B&C consumer guides
_____E. Other: (SPECIFY)1. _________________________
2. _________________________
3. _________________________
4. _________________________
4. Are there unlicensed board and care homes in your state?
_____ Yes
_____ No (IF NO, SKIP TO QUESTION 8.)
5. Can you estimate the number of unlicensed homes in your state?
Enter number of homes: _____
6. In your opinion how effective is your state in identifying unlicensed board and care homes?
7. In your opinion how effective is your state in closing unlicensed homes?
8. Are you satisfied with the current division of responsibility for board and care homes within your state?
_____ Yes
_____ NoComments:
NATIONAL BOARD AND CARE SURVEY DESIGN REPORTS AVAILABLE
Searching for a Needle in a Haystack: Creative Use of the Decennial Census Dress Rehearsal Data to Find Board and Care Places in Central Missouri
Executive Summary http://aspe.hhs.gov/daltcp/reports/1992/haystkes.htm
HTML http://aspe.hhs.gov/daltcp/reports/1992/haystk.htm
PDF http://aspe.hhs.gov/daltcp/reports/1992/haystk.pdf
INSTRUMENTS AVAILABLE
All Respondents Questionnaire
HTML http://aspe.hhs.gov/daltcp/instruments/AllResp.htm
PDF http://aspe.hhs.gov/daltcp/instruments/AllResp.pdf
Interagency Councils Questionnaire
HTML http://aspe.hhs.gov/daltcp/instruments/IntCoun.htm
PDF http://aspe.hhs.gov/daltcp/instruments/IntCoun.pdf
Licensure Questionnaire
HTML http://aspe.hhs.gov/daltcp/instruments/Licensure.htm
PDF http://aspe.hhs.gov/daltcp/instruments/Licensure.pdf
Local Agency Questionnaire
HTML http://aspe.hhs.gov/daltcp/instruments/LocalAg.htm
PDF http://aspe.hhs.gov/daltcp/instruments/LocalAg.pdf
Local Ombudsman Questionnaire
HTML http://aspe.hhs.gov/daltcp/instruments/LocalOm.htm
PDF http://aspe.hhs.gov/daltcp/instruments/LocalOm.pdf
Payment/Eligibility Questionnaire
HTML http://aspe.hhs.gov/daltcp/instruments/PayElig.htm
PDF http://aspe.hhs.gov/daltcp/instruments/PayElig.pdf
To obtain a printed copy of this report, send the full report title and your mailing information to:
U.S. Department of Health and Human Services
Office of Disability, Aging and Long-Term Care Policy
Room 424E, H.H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201
FAX: 202-401-7733
Email: webmaster.DALTCP@hhs.gov