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Volunteer Report
Report of home visits for Welcome Baby Volunteers
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* Indicates required question
Name of Volunteer
*
Your answer
Date of Visit
*
MM
/
DD
/
YYYY
Parent's Name
*
Your answer
Who did you visit with?
*
Mother
Partner
Both
Other:
How many hours did you spend on this visit, including preparation (round up)?
*
1 Hour
2 Hour
3 Hour
4 Hour
Type of Visit
*
First Visit
Second Visit
Both First and Second
Long Term
Format
*
In-person visit
Virtual Visit
Did you ask if they applied for Medicaid?
*
Yes
No
Did they or are they planning on applying to Medicaid?
*
Yes
No
I will contact them and ask
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