This survey is designed to be quick and easy and involve little description.  Each entry that you make represents the work of ONE nurse/health minister.  Please select from dropdown menus.  You DO NOT have to answer every question.  You DO have the option of adding description to each question, but this is not required.  This survey takes about 5 minutes to complete.

Question Title

* 1. For what month(s) are you reporting hours

Question Title

* 2. Who completed these hours (first and last name)?

Question Title

* 3. What is the name of the community served (may be a faith community, geographic community or other)?

Question Title

* 4. Describe the service (in person or remote/distant) performed during this period by selecting from options in the drop down menu.  If activity isn't covered here, please describe below.

  Yes/No # minutes # individuals served # classes or group sessions held
Blood pressure check
Transitional care
Palliative care
Other visit (i.e. spiritual care)
Individual Advance Care ed/assist
Group Advance Care ed/assist
Referrals to community programs
Support group hosting or assistance (i.e. addiction/recovery)
Teach, lead or organize preventive health ed. not listed here.  Describe below.
Community program support (food, writing, prayer, etc.)
Mentorship to other FCNs or HMs
Ask a Nurse Program

Question Title

* 5. Describe the continuing education activities that you participated in during this period.

  Yes/No Number of hours
Attend HMN monthly meetings
Attend professional education (for CEs)
Attend professional education (no CEs)
Attend spiritual formation

Question Title

* 6. How would you improve this survey?

Question Title

* 7. What type of support or continuing education would you like to receive from HMN?

Question Title

* 8. If you would like a copy of your survey to be sent to you for reporting elsewhere, please include an email address here:  

T