If you have more than one patient please use separate forms.
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* = Required
*
Volunteer Name:
If DS Volunteer, enter the Patient Initials:
Day 1
*
Date of Service:
ex. 01/01/2003
*
Type of Service:
Select One:
Administrative
Bereavement
Community Support
Training
Direct Service
Kline Hospice House
In-Services
Camp Jamie
Hospets
Standard Precautions
*
Site of Service:
Select One:
Home
Nursing Home
Hospice Office
Hospice House
Activities:
Shopping
Meal Preparation
Light Housekeeping
Yard Work
Laundry
Companionship - Patient
Respite - Caregiver
Emotional Support: Patient
(- Telephone Call)
Emotional Support: Caregiver
(- Telephone Call)
Attend Funeral/Memorial Service
Attend Viewing/Wake
Bereavement:
Select One:
Telephone Call
Support Groups
Cards/letters
Camp Jamie
Other (Specify:)
Organizational Activities:
Community Support (fundraisers)
Community Education (health fair, speaking engag.)
Administrative Support
*
Hours worked:
ex. 5.25
( round to quarter hours 15min = .25 )
At this point you can continue to add information for additional days you have volunteered. Would you like to add another day?
Yes, I would like to add another day:
No thank you, proceed to next step:
Clear form and start over:
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