Pine Tree Hospice
Volunteer Time Sheet and Client Services Record

Dear Volunteer...

Our funding and our licensure depend on accurate records of your hospice, bereavement and/or Evergreen services.

We need to know every two weeks how many hours you spend for

indirect service [no client contact],

and direct service [client or family contact].

Also, for direct service to clients, we need a brief comment
about each visit.

Please complete and send the electronic form below,

OR use this website to print and mail a copy of the

Volunteer Time Sheet for indirect service and the

Client Services Record if you also provide direct service,

OR visit our office to pick up copies of the forms

Directions for the electronic form (below): 

  • Use your mouse to click on the shaded box next to "Your Name",
    and begin by filling in your name.
  • Use the TAB KEY to move through the form or use your mouse to click on any field; do not use the ENTER key to navigate the form. 
  • The 3 silver-shaded fields are required. 
  • Please enter time in quarter-hour segments, expressed as a decimal
    (for example: 10.25).
  • Please add a brief explanation or comment for each entry.
  • A memo field is provided at the end for more details if you wish.
  • All data is sent via e-mail exclusively to the PTH office, however for added security, we ask that you include initials only for your client(s).
  • If you have more than one client or if you need more room, you will be given a chance to submit an additional form after you submit this one.
  • When you have finished, scroll to the bottom and select one of the buttons to send [or not send] your data.
Your Name: (required)

 
Dates for this Report: (required)

 

Indirect Service Hours  [no client contact]

Number of hours in quarter-hour segments, please,
expressed as decimal (for example: 10.25)                  Brief Explanation
Office hours

Continuing
Education		 hours
  

Committee
Meetings		 hours

Provide
Meals		 hours
  

Public
Relations		 hours

Travel hours

Other
Hours		 hours

TOTAL INDIRECT SERVICE HOURS: 

Direct Service Hours [client or family contact] 
Please enter number of hours for each date, with a brief comment
Client's initials:    (More than one client, or not enough room on the form?
                                               We will give you the chance to come back here)

Date
and
Comments

Hours
quarter-hour segments, please,
expressed as decimal (for example 1.75)
Visit Client or Family Phone Contact Travel Time and / or Errands TOTAL
each day
Date

Comment
initials only

Date

Comment
initials only

Date

Comment
initials only

Date

Comment
initials only

Date

Comment
initials only

Date

Comment
initials only

Date

Comment
initials only

TOTAL DIRECT CARE CLIENT SERVICE HOURS: 

Evergreen Service Hours
 Please enter number of hours followed by a brief explanation
Direct
service		 hours

Indirect
service		 hours

Additional Explanation or Comments  [client initials only, please]

TOTAL HOURS
of indirect and direct service for
 Hospice, Bereavement and/or Evergreen
for this time period:  (required) 		 
Please call Amy Madigan-Dube, your Coordinator of Volunteer Services,
if there are any changes in your client's status or if you have any questions
or concerns.  Call Amy at 207-564-4440.

Note:  You may print this form for your records
BEFORE you submit it
(select "Print" from your web browser)

 

Thank you, Volunteer, for ALL THAT YOU DO !!!

I'd rather fill in a printed page

Escape to home page without filling in the form


 

Copyright © 2008 [Pine Tree Hospice]. All rights reserved.   Revised shpc: 08/17/09