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* 1. Volunteer

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* 2. Client (First name, Last initial)

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* 3. Date of Contact

Date

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* 4. Type of Contact

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* 5. Please share a bit about your visit with the client, caregiver or family. REMINDER: Your stories are the most important part of your log! Please don't leave this blank.

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* 6. Total Mileage (Mileage to and from client AND during visit. Use numbers only.)

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* 7. Activities:
Please list the total # of hours spent on each task during this visit.  (Please round to nearest half hour. Use numbers only.)

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* 8. Total Visit Hours (add up hours from q. 7. Use numbers only.)

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* 9. If you provided transportation, please specify to and from what services

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* 10. Were you relieving a family caregiver who would usually perform these activities?

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* 11. Is this caregiver/family in need of additional support?

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* 12. Was there a decline in the client's status from your last visit?

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* 13. Volunteer Travel Time (time to and from client, NOT travel time during visit)

T