Hospice Volunteer Activity Report

Volunteer Activity Record

*Travel time should be included when traveling to a patient location.

Visit Date including year (mm/dd/yyyy):

Visit Time In (hh:mm AM or PM)

Visit Time Out (hh:mm AM or PM)

*Roundtrip mileage to and from a patient location (not office) should be recorded - Be sure to divide mileage if seeing multiple patients at the same location

Visit Canceled

Site of Service

Activities Performed

Details or Additional Comments: