Volunteer Visit/Call Documentation

Patient ID # *
Team *

Type of Contact

Visit/Phone Call *
Date (MM/DD/YYYY) *
Hour(s) *
Minutes *
Volunteer Visit Declined
Travel Time
(Total for all visits; enter 0 if no travel was required.)
Hour(s) *
Minutes *
Total Volunteering Time
(Includes phone calls, visit time & travel time.)
Hour(s)
Minutes

General facts regarding visit/phone call

Please check your volunteer visit type only (if you made a visit). If you made a phone call, please check phone call. *

Please do not include any personal health information in the fields below.

Bereavement Visit/Call
Companionship to Patient/Caregiver
Cosmetology Services
Errands
Financial/Legal Paperwork
Funeral
Household Assistance
Massage Therapy
Meals/Baker/Caterer
Music Visit
Notary Services
Pet Visit
Phone Call
Respite
Transitional Care Visit/Call
Transportation
Yard/Garden Assistance
Other
Volunteer Name *
By checking this box, I certify that this is my electronic signature and that I am authorized to submit this information. *
By checking this box, I certify to the best of my knowledge that there is no identifying personal health information included in this submission. *