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Volunteer Activity Record Form
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* Indicates required question
Volunteer Name
*
Your answer
Patient Name
(if applicable)
Your answer
Date of Activity
*
MM
/
DD
/
YYYY
Visit Start Time
*
Time
:
AM
PM
Visit End Time
*
Time
:
AM
PM
Round Trip Travel Time
(add only to first visit if seeing multiple patients at the same facility)
Time
:
AM
PM
Volunteer Services Provided
Direct Patient Care
*
NONE
Caregiver Relief
Light Housekeeping
Inpatient Unit
Companionship
Special Occasion
Transport
Errands
Bereavement Calls
Spiritual Support
Light Meal Preparation
Funeral
Required
Administrative Services
*
NONE
Clerical Work in the Office
Public Relations
Special Projects
Other:
Required
Notes
Your answer
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