Emmanuel Hospice Volunteer Report

Notes: Do NOT include any patient identifying information such as name, address, facility name or phone. Only one contact per form. This form is to be submitted within 5 days of contact.

Volunteer Name*
First Last
Patient Record Number*
Date of Contact*
MM slash DD slash YYYY
COVID Screening: Did the volunteer complete the Volunteer Pre Visit Screening Tool?*
- Yes
- No
Did volunteer confirm with patient/caregiver that patient has no COVID symptoms?*
- Yes
- No
Were you able to complete this visit? (Ie. Patient accepted or declined a visit upon arrival)*
- Yes
- No
Please explain why the visit was not able to be completed.*
Patient Time IN*

: Hours

Minutes

AM/PM
Patient Time OUT*

: Hours

Minutes

AM/PM
Total Visit Time with Patient (in minutes)*
Travel Time (in minutes)*
Total Time (patient time + travel time in minutes)*
Round Trip Milage*
Type of Visit*
- In-Person
- Phone
Location of Patient*
- Home
- Nursing Home
- Assisted Living/Adult Foster Care
- Independent Living
- Hospital
Services Provided (select all that apply)*
- Telephone Support
- Caregiver Respite
- Bereavement Contact
- Assist w/Meal Prep
- Light Household Tasks
- Life Review
- Spiritual Support
- Companionship/Support
- Friendly Visit
- Veteran to Veteran Support
- Other
Other Services Provided
Services Provided by Specially Trained Volunteers (select all that apply)
- Massage
- Music Therapy
- Pet Visitor
- Haircut/Style
- Art Legacy
- Virtual Reality
- Photography
- Other
Other Services Provided
On Arrival, The Patient Was In*
- Wheelchair
- Reclining Chair
- Bed
On Arrival, The Patient Was Located In*
- Patient Room
- Hallway
- Activity Area
On Arrival, The Patient Was (select all that apply)*
- Awake
- Non-Responsive
- Easily Roused
- Asleep
- Other
Other
At The End of The Visit, The Patient Was (select all that apply)*
- Alert
- Talkative
- Comfortable
- Agitated
- Relaxed
- Asleep
- Other
Other
Did The Patient Complain of Pain?*
- No
- Yes
If Yes, Tell Us What You Did About It (select all that apply)
- Patient Took Medication
- Notified The Caregiver
- Patient Refused To Take Medication Left By Caregiver
- Notified The Hospice Office
- Other
Other Actions Taken (no patient identifying information)
Did The Patient State That They Were Short Of Breath?*
- No
- Yes
If Yes, Tell Us What You Did About It (select all that apply)
- Patient Applied Oxygen
- Refused To Take Medication Left By Caregiver
- Patient Took Medication
- Notified The Hospice Office
- Notified The Caregiver
- Other
Other Actions Taken (no patient identifying information)
Please provide a brief summary of your visit, including any declines noted since your last visit*
Your Next Scheduled Contact (if applicable)
MM slash DD slash YYYY
Signature (use cursor for computer, finger for phone/tablet)*
Confirm that you have completed this form as truthfully and accurately as possible.

Contact Emmanuel Hospice

401 Hall St SW, Suite 263
Grand Rapids, MI 49503

616.719.0919

info@emmanuelhospice.org

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