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Call Hospice of Helping Hands: 800-992-6592
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Electronic Volunteer Report Form

Please complete the entire form and submit this form to the Volunteer Coordinator within 3 days of volunteer service.

We are required by CHAP and Medicare requirements to document all patient visits by volunteers.

Non-patient volunteer activities can still use this form. Make sure you complete all fields related to your volunteer service.

Volunteer Name
Date of Service
Medical Record #
Time I Left My Home
Time I Arrived At Patient Home
Time I Left Patient Home
Time I Arrived Home
Total Miles
Activity During Visit
Sat With Patient
Visited
Played Games/Cards
Light Housekeeping
Phone Call
Other
Patient/Caregiver Response to Care or Service by Volunteer
Satisfied
Unsatisfied
Comments
All Other Volunteer Services (check the box that applies)
Office
Health Fair
Meeting
Training
Promotion/Distribute Flyers
Hearts for Hospice
Yard Sale
Duck Race
Quilt Show
Golf Outing
*I certify that all information reported on this form is correct and that checking this box serves as my electronic signature.
Submit