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Volunteer Visitor Form

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 enter the above text in the box below and click submit

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