Direct Patient Care Online Volunteer Activity Report

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Patient Name(Required)

First Last

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Patient ID Number(Required)

Date of contact:(Required)

Location(Required)

Please select one.

Houston
El Campo/Wharton

Where were your volunteer services provided?(Required)

Home visit
IPU
Nursing/Personal Care Home
Phone support
Funeral Home/Service

Specific services provided:(Required)

Check all that apply.

Sat quietly with patient
Read to patient/family
Emotional support/talking/sharing with patient/family
Bereavement visit
Funeral service (attended)
Household chores/prepared meals
Pet Therapy
Chaplaincy/Spiritual support - patient/family
Interpreter/Translating

Issues Requiring Staff Attention

Issue(s)(Required)

ISSUE(S) MUST BE REPORTED IMMEDIATELY. Use this area ONLY for emergencies ALREADY REPORTED to Houston Hospice Staff.

No issues to report
Physical
Social/Emotional
Spiritual
Bereavement

To whom was the issue reported?

First Last

What was the outcome?

Is there additional information related to the issue?

Visit Summary

Summary

Please provide any additional details, including patient/family response to volunteer services.

Have you planned another visit?(Required)

Yes
No

If yes, when is your next visit?

Visit Details

Start time:(Required)

:

Total time (For example: 1 hour, 15 minutes)(Required)

Round trip mileage:

Travel time, round trip (in hours and minutes):

Volunteer Signature(Required)

By typing your name, you attest the information provided above is correct and true.

First Last

Phone

This field is for validation purposes and should be left unchanged.