Bereavement Volunteer Contact Report Revised

Bereavement Volunteer Contact Report
Volunteer's Name*
Date of Contact*

MonthDayYear
Date
Name of Bereaved*
Chart #*
Name of Deceased*
DOD*
Relationship to Bereaved*
Contact month:*

3 month6 month9 month12 month
Date of first attempt phone call:*

MonthDayYear
Date
Time of first attempt phone call: beginning until end of call including am/pm*
Type of Contact:*

Telephone conversationLeft messageUnable to leave message
Date of second attempt phone call

MonthDayYear
Date
Time of second attempt phone call: beginning until end of call including am/pm
Type of contact:

Telephone conversationLeft messageUnable to leave message
Does the client wish to continue receiving these supportive calls?*

YesNoUnknownN/A (12 month call)
Comments:
Call with any situation that requires immediate attention [607-272-0212]. Submit this contact report to Bereavement Services Administrative Assistant within one week of the call, or by the 5th of the month following the call. Indicate if the client wants to continue to receive calls or not
By checking this box and typing my name below I am electronically signing my name.
Volunteer's Name:*
Date*

MonthDayYear
Date
Should be Empty: