Volunteer

Name of Volunteer:
Volunteer Email Address:
First and Last Name of Ward:
Facility:		Date of Visit:
Location of Visit:
Length of Visit:
(in minutes, including time spent with staff and reviewing records)

Appearance of Ward: (Check All That Apply)
Neat	Ambulates without assistance
Unkempt	Ambulates with cane
Clean	Ambulates with walker
Dirty/Stained Clothes	Ambulates with wheelchair
Dressed Inappropriately
Dressed Appropriately

Mood of Ward: (Check All That Apply)
Appropriate	Thought Content Inappropriate
Angry/Hostile	Short Attention Span
Troubled, Sad, or Depressed	Unable To Determine
Non-verbal	Interaction Active
Converses	Interaction Passive

Describe Visit:	Yes	No
Did the ward acknowledge your presence?
Was the ward doing any activities?
Was the ward satisfied with the care?
Was the ward satisfied with the staff?
Was the staff available to answer questions?

Please provide a brief narrative describing your visit, including descriptions to your answers above. What did you and the ward do? What did you talk about? Any specific concerns or progresses?

(Please type in all lower-case for data entry purposes)

Please enter the above text in the box below and click submit

[ Different Image ]