Volunteer Visit Report

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* 1. Volunteer Name:

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* 2. Client Name/ID:

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* 3. Visit Date:

Please respond:

Date

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* 4. Visit Types:
(Please check all appropriate items for this visit and document phone calls)

	Check here if applicable:
Client Contact/Activity	Client Contact/Activity Check here if applicable:
Community Education	Community Education Check here if applicable:
Hospice House North	Hospice House North Check here if applicable:
Hospice House South	Hospice House South Check here if applicable:
Music	Music Check here if applicable:
Office	Office Check here if applicable:
Paws for Comfort	Paws for Comfort Check here if applicable:
Phone Call	Phone Call Check here if applicable:
Reiki	Reiki Check here if applicable:
Spiritual Support	Spiritual Support Check here if applicable:
Vigil	Vigil Check here if applicable:
Volunteer Training/In-service	Volunteer Training/In-service Check here if applicable:

Other (please specify)

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* 5. Visit Start Time:

Please respond using 15 minute increments: e.g. 1:15pm

Time

AM/PM

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* 6. Visit End Time:

Please respond using 15 minute increments: e.g. 1:15pm

Time

AM/PM

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* 7. Travel Round Trip:

	Hours	Minutes
Please respond:	Please respond: Hours menu	Please respond: Minutes menu

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* 8. Mileage Round Trip:

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* 9. Contact with Team?

	Yes	No
Please respond:	Please respond: Yes	Please respond: No

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* 10. Brief description of activity/visit:

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* 11. Frequency of visits?

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* 12. Certification of Identity:

I attest that I am the person whose name and information is listed above. I also attest that the information contained in this survey is accurate and complete to the best of my knowledge.

Thank you for being part of Hospice of Spokane. We appreciate the support you have given. (Please leave question 13 blank. This is for office use). Thank you.

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* 1. Volunteer Name:

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* 2. Client Name/ID:

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* 3. Visit Date:

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* 4. Visit Types:(Please check all appropriate items for this visit and document phone calls)

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* 5. Visit Start Time:

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* 6. Visit End Time:

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* 7. Travel Round Trip:

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* 8. Mileage Round Trip:

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* 9. Contact with Team?

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* 10. Brief description of activity/visit:

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* 11. Frequency of visits?

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* 12. Certification of Identity: I attest that I am the person whose name and information is listed above. I also attest that the information contained in this survey is accurate and complete to the best of my knowledge.

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* 13. Initial for Verification-Office:____ MSW:_____

* 4. Visit Types:
(Please check all appropriate items for this visit and document phone calls)

* 12. Certification of Identity:

I attest that I am the person whose name and information is listed above. I also attest that the information contained in this survey is accurate and complete to the best of my knowledge.

* 13. Initial for Verification-Office: MSW:_