Volunteer Contact Report
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Work
*
Patient Visit
Office Work
Patient Name
*
First Name
Last Name
Pre-Visit
Does patient or family have a fever, shortness of breath or respiratory symptoms?
*
No
Yes
Hospice Director contacted @ 402-375-4288 prior to patient visit.
Has patient or family been exposed to anyone that has tested positive for Coronavirus?
*
No
Yes
Hospice Director contacted @ 402-375-4288 prior to patient visit.
Has patient or family traveled in the last 14 days??
*
No
Yes
When and Where was the travel?
*
Post-Visit
Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Stop Time
*
Hour Minutes
AM
PM
AM/PM Option
Respite
Errands
Transportation
Personal Care
Housework
Visiting
Meals
Phone Calls
Visitation/Funeral
Bereavement Visits
Other
Comments
Patient wore PPE? (mask)
*
Yes
Refused
No
Volunteer wore PPE? (mask)
*
Yes
No
Family and/ or Friends wore PPE? (mask)
*
Yes
Refused
Comments Related to PPE
Volunteer Signature
Volunteer Name
First Name
Last Name
Submit
Should be Empty: