Volunteer Activity Report

If you are a current Yolo Hospice volunteer, please use this form to submit information about your volunteer activities to our Volunteer Coordinator.

Volunteer Name*
First Last
Patient Name*
First Last
Activity Date*
Arrival time for activity*

: Hour

Minute
Round-trip Mileage*
Round-trip Travel Time*
Hours & minutes
Direct Time*
Please type time in hours and minutes (round to 15 minutes). Examples of DIRECT time include: visit with patient, relief for primary caregiver, visit with patient’s family, light housekeeping, child care, reading, writing, errands, shopping, singing, playing music, attending patient’s funeral. (Does not include TRAVEL time.)
Indirect Time*
Please type time in hours and minutes (round to 15 minutes). If none, put zero. Examples of INDIRECT time include: telephone call to patient/patient’s family/caregiver, telephone call to patient’s care facility, telephone call or meeting with hospice staff regarding your patient, telephone call from hospice staff coordinating delivery of medications/supplies. (Does not include TRAVEL time.)
Activity Report*
Report Discussed With
- RN
- MSW
- Chaplain
- Volunteer Services Manager
- Other
Other (please specify)
Comments
This field is for validation purposes and should be left unchanged.