Resident Outing Application-Family

We know how important it is to spend time with your loved ones outside of the facility, visiting other family, eating meals together, and enjoying the holidays.


We are advising to always keep COVID-19 risk-reduction in mind when taking your loved one out on an outing.


Some steps, that you can do to help reduce the risk of spreading COVID-19 are:

•    Wearing a mask in public and enclosed spaces

•    Practicing social distancing

•    Reporting any potential exposures in the last 10 days

•    Reporting any signs or symptoms of illness of anyone that attended the outing, even if it is days later

•    Ensuring that you and others are up to date with their COVID-19 vaccinations

•    Testing either at home with test kits or here when you come to visit


We will observe your loved one for any signs or symptoms of illness upon their return and test if necessary.


Thank you for helping us keep your loved one safe and COVID-19 free.


Please contact Erin Leutzinger, Infection Preventionist if you have any questions at (402) 334-6525.

Resident Details

Resident's first and last name

Room number*

Please select the Resident's room number.

Requestor Contact Information

First and last name please

Your phone number, in case we need to contact you.

Phone

Your email address, in case we need to contact you and are unable to reach you by phone.

What is your Relationship to Resident*

Event Details

What time would you like to pick up your loved one?

What time would you be planning on returning your loved one?

Outing Type*

If the outing is a scenic drive ONLY, then please select Scenic Drive. If the outing is going to a private home, please select Home Visit. If neither of these options are correct, please select Other-Public Space.

Where is the outing?*

If the outing is going to someone's home, please select Residential. If the outing is going to a public place like a restaurant or a shopping mall or retail store; like Target or Kohl's, please select Commercial. If neither of these options are correct, please select Other- Public Space and explain where you plan on going.

Please explain what Other-Public Space is. Some examples of this might be a public park or another type of entertainment venue.

What is the name of the location you are going to go? Some examples might be the name of the restaurant, mall/store.

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