Patient Name:
HHC #:
Facility:
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:
Mailing
Phone call
Visit to:
Home
Nursing Facility
Hospice Inpatient Unit
Other:
Visit From:
Chaplin
Volunteer
Pets
Bereavement
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
Errands/shopping/delivery
Music/singing
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: