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Zoom Support Check Out
Please complete this form after each SHIFT. Results will be used to inform the project over time. Please do not include personal information about participants. Thank you!
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* Indicates required question
Email
*
Your email
Your name
*
Your answer
Shift date (HST)
*
MM
/
DD
/
YYYY
Shift start time (HST)
*
Time
:
AM
PM
First names of facilitators (including you)
*
Your answer
# of
HELPERS
that dropped in for support
*
Your answer
What role(s) were the
HELPERS
in (if known; e.g., nurse, teacher, hotel staff)
Your answer
What services did YOU provide?
Supportive listening
Info on zoom support room
Referral for mental health services
Referral for crisis services
Referral to Maui Rapid Response
Other referral (list type(s) below)
Other:
What other needs did the
HELPER(S)
have?
Your answer
Where did the
HELPER(S)
hear about the room? (only if appropriate to ask or offered without prompting)
Your answer
Why did you volunteer? (only if you haven't responded before)
Your answer
What did you most enjoy about this experience? (optional)
Your answer
What else can we do to support you? Any comments/questions/feedback?
Your answer
MAHALO! We are so grateful for your time and support.
If you have any questions or concerns or something not captured in the form, please email mauikokua@gmail.com or dr.dlogan@gmail.com
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