All fields are required, if a field is not applicable, please put n/a in the box.
Date*
Requester's Name*
Department*
Assignment Request / Patient's Name*
Street Address / KFHR Room #*
City
State
Zip
Contact Name*
Contact Phone*
Contact Role*
Activity Category: Patient Facing* CompanionshipVeteranRefused / DeclinedN/A
Activity Focus: Companionship —Please choose an option—Sense of Connection with hospice VolunteerAn Improved Sense of CompanionshipAn Improved Sense of SupportAn Improved mood/attitude through Volunteer activities
Activity Measurement: Companionship —Please choose an option—Patient / Caregiver expression of improved moodPatient / Caregiver reports on volunteer activitiesPatient / Caregiver volunteer reviews
Activity Focus: Veteran* —Please choose an option—Military Service focused Connection and ConversationMilitary Service honorsRecognition and Thanks for their military ServiceN/A
Activity Measurement: Veteran* —Please choose an option—Patient / Caregiver expression of improved moodPatient / Caregiver reports on volunteer activitiesPatient / Caregiver volunteer reviewsN/A
Is a Veteran Volunteer being requested?* —Please choose an option—YesNoN/A
If a Veteran Volunteer is not available would the patient accept a non-Veteran Volunteer?* —Please choose an option—YesNoN/A
Activity Category: Patient Refused / Declined Volunteer* (choose all that apply) Continued availability of volunteer services despite those services currently being declined by the patient/familyIDG documentation of patient discussionN/A
Volunteer Intervention Activities* 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 / TVOther If Other (Intervention Activities), please specify
Duration* —Please choose an option—3 Days7 Days14 Days30 Days90 Days180 DaysEnd of Current Benefit Period
Frequency of Visits* 1 to 2x / Month2 to 3x / Month3 to 4x / MonthPer Patient RequestOther If Other (Frequency), please specify
Careers
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