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Contact Record / Activities
Patient Name
Date
MM slash DD slash YYYY
Volunteer
Location
Time In
Time Out
Travel Time
Mileage
Contact Type
*
Select below and then see applicable questions
Patient / Family Visit
Telephone Call
Bereavement Support
Patient / Family Visit
Activities Performed
(check all that apply)
Respite
Errands
Bucket List
This Is Your Life
Memory Boards/Correspondence/ Photo Albums
Complimentary Therapies/Music
Telebuddies
Vet-to-Vet
Veteran Pinning
Outdoor Tasks
Personal Touches
Companionship
Pet Care
Meals of Love
Cakes of Occasions
Was the patient experiencing pain, shortness of breath, or other symptoms?
Yes
No
If yes, who was contacted regarding the patient issue above.
Did the patient/family request additional support, such as the social worker or chaplain?
Yes
No
If yes, who was contacted regarding the patient issue above.
Notes
COVID Screening
*
Volunteer has completed the Covid-19 Employee Screening Assessment
Volunteer Signature
*
Telephone Call
Person Contacted
Patient
Primary Caregiver
Family Member/Friend
Notes
COVID Screening
*
Volunteer has completed the Covid-19 Employee Screening Assessment
Volunteer Signature
*
Bereavement Support
Activity
Telephone Call
Funeral Visit
Visit to Family
Other
Notes
COVID Screening
*
Volunteer has completed the Covid-19 Employee Screening Assessment
Volunteer Signature
*