Patient Name:

HHC #:


Volunteer Documentation Form
Volunteer Name:
Date of Contact (MM/DD/YYYY):
Miles (round trip): Total Hours (include travel time):
Reimbursement for mileage requested?  Yes No
Type of contact:
Phone call
Visit to: Home Nursing Facility Hospice Inpatient Unit
Visit From:  

  Services Provided (check all that apply): Brief Comments/Description:
First contact to patient caregiver
Social support/visiting for patient caregiver
Emotional support to patient caregiver
Sitting with patient
Active listening
Meal/food preparation
Meal/food delivery
Transportation for patient caregiver
Assistance with personal care
Encouraged patient caregiver to reminisce
Flower/gift delivery
Caregiver respite/break
Reading/letter writing
Encouragement card
Support/Check-in phone call
Anticipatory grief education/support
Support at time of death
Bereavement support
Funeral attendance
Volunteer email: