Pine Tree Hospice
Volunteer Time Sheet and Client Services Record

Dear Volunteer...
Our funding and our licensure depend on accurate records of your hospice services.

Please complete and send this form every month, OR print and mail a copy of the Volunteer Time Sheet for indirect service (no client contact) and the
Client Services Record if you also provide direct service (client or family contact).

Directions: 

  • Use your mouse to click on the shaded "Your Name" data input area, and begin by filling in your name.
  • Use the TAB KEY to move through the form or use your mouse to click on any data input areas of your choice; do not use the ENTER key to navigate the form. 
  • The 3 silver-shaded fields are required. 
  • Please enter time in 1/4 hour segments with a brief explanation; 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, we ask that you include initials only for your hospice client(s).
  • Scroll to the bottom and select one of the buttons to send/not send your data.
Your Name: (required)

 
Month and Year for this report: (required)

 

Indirect Service Hours  (no client contact)
Please enter number of hours followed by a brief explanation
Evergreen
Office
Continuing Education
Committee Meetings
Providing Meals
Public Relations
Travel
Other Hours

TOTAL INDIRECT SERVICE HOURS: 

 
Direct Service Hours (client or family contact)
Please enter number of hours followed by a brief explanation
Client #1's initials:
Date(s) of visit/call
Client visit
Respite care
Phone contact
Transport client
Errand travel
Other hours
Travel

Total for Client #1
Client # 2's initials:
Date(s) of visit/call (#2)
Client visit (#2)
Respite care (#2)
Phone contact (#2)
Transport client (#2)
Errand travel (#2)
Other hours (#2)
Travel (#2)

Total for Client #2

TOTAL DIRECT CARE CLIENT SERVICE HOURS THIS MONTH:

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

Additional Explanation or Comments  [client initials only, please]:

TOTAL HOURS of indirect and direct service
 Hospice &/or Evergreen for this month:  (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.

 

Thank you, Volunteer, for all that you do

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Copyright © 2008 [Pine Tree Hospice]. All rights reserved.   Revised shpc: 06/26/08