Resident’s name__________________________________________________________________________

Resident's age_____

Resident's sex_____

Does the Resident have a roommate?  Yes_________    No__________

Name of Guardian or POA (circle applicable one)_________________________________________________

Guardian's address & phone___________________________________________________________________

Name of nursing home________________________________________________________________________

Nursing home address_______________________________________________________________________

Nursing home phone number:_________________________________________________________________

Resident's room number:______

Name of nursing home's administrator__________________________________________________________

Who owns this home?________________________________________________________________________

How often does a family member visit the resident?_______________________________________________

What problems, if any, are you experiencing at the nursing home? Please be brief.

Have you filed complaints with the Administrator? What were the results?

Have you filed complaints with the Ombudsman? What were the results?

Do you realize that there may be retaliation against you or your loved one by the nursing home as a result of installing a surveillance camera? Yes____ No_____ Are you willing to take this risk? Yes_____ No_____

Signature and date_____________________________________________________

Are you willing to challenge your right, in court if necessary, to use a surveillance camera to monitor the care of your loved one? Yes_______ No________

Signature and date______________________________________________________

Directions: Please fill out this form and enclose a copy of your Guardianship Papers or Power of Attorney fax or mail to: Nursing Home Monitors, 6111 Vollmer Lane, Godfrey, IL 62035. Fax number: (618) 466-3410.  We will call you upon receipt of the application form.

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