Volunteer Charting Form

Date*

Your Name*

Assignment Request / Patient Name*

Location of Activity*
—Please choose an option—CommunityKaplan Family Hospice ResidenceOffice - 800 Stoney Brook CourtOffice - MiddletownRemote

Activity Start Time*

Activity End Time*

Travel Distance (Round Trip in Miles)*

Travel Time (Total in Minutes and/or Hours)

Activity Category: Patient Facing*
CompanionshipVeteranRefused / DeclinedN/A

NOTE: Refused / Declined Today's Visit
(If the patient refuses or declines your visit, please explain the circumstances)

Volunteer Activities - Patient Facing* (choose all that apply)
AdvocacyCrafting ProjectComforting Presence / Comforting TouchCompanionshipEngage in HobbiesErrandsLight HousekeepingListen to Life Stories / MemoriesListen to Music / Sing SongsMeal Preparation AssistancePlay Board Game or CardsPray / MeditateRead Aloud to PatientRecord MemoriesRespite or Hospitality for the Family / CaregiverSit VigilWatch Movie / TVN/AOther
If Other (Patient Facing), please specify

Volunteer Activities - Bereavement*
Bereavement Phone Calls to FamilyBereavement MailingsBereavement Vigil Care BoxesN/A

Volunteer Activities - Administration*
800 Building Administration800 Building Advancement800 Building Finance800 Building Front DeskKaplan Family Hospice Residence - Front DeskKaplan Family Hospice Residence - AdministrationN/AOther
If Other (Administration), please specify

Additional Description of Activities
(Optional: add any additional information related to your activity here)