Please complete one page per visit- One page for NH visit and one for RCF if both visited on same date.  Complete and submit forms upon completion; but no later than 3 days following visit.  Reports will be reviewed by the Regional Program Director and feedback will be provided accordingly.

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* 1. Volunteer Name

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* 2. Council President Name

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* 3. Facility Name and Type

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* 4. Zip Code

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* 5. Travel Time

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* 6. How long were you at Council Meeting.

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* 7. Date of Meeting

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Time

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* 8. Total Attending

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* 9. Comments, Issues, are things being resolved each month?

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* 10. Highlight of the Meeting/ Recommendations

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* 11. Staff Presence

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