Volunteer Progress Record

Volunteer Progress Record
Patient Name

First Name Last Name
Date of Activity

Month Day Year
Date
Travel Time (Round Trip): minutes + Visit Time minutes =Length of contact: minutes
*Note - if more than 1 patient is seen at the location, please divide the travel time between the number of patients.
Patient Care Activity

Activity Assistant Beautician Companion Handyman Housekeeping Massage Therapy Music Pet Therapy Prepare Meals Respite Other
Non-Patient Activity

Baking Gardening Office Bereavement Support Calls Special Event Other
Safety Precautions Followed Per Plan of Care:

Yes No
Patient Appearance:
Alertness:

Awake Asleep
Participation:

Active Passive
Mood:

Good Fair Poor
Conversation:

Appropriate Confused No Response
Visit Notes:
Volunteer Name

First Name Last Name
I certify that all of my responses are complete and accurate.
Signature

Clear
Mileage
Should be Empty: