Volunteer Contact Log

Cortland: 11 Kennedy Parkway Cortland 13045 Tompkins: 172 E. King Rd Ithaca 14850

Telephone: 607-272-0212 Fax: 607-272-0237
Patient Name*
Date of Contact*

MonthDayYear
Date
Volunteer Name*
HomeHospicare ResidenceNursing home / Assisted livingHospitalFuneral / calling hours
Respite with family presentRespite with family goneCompanionshipFriendly, supportive phone callLight housekeepingRunning errands / grocery shoppingVigil with dying patientMassageThreshold ChoirBereavement visitOther (describe in the comments below)
Time of beginning of visit until time of end of visit, including a.m. or p.m.*
Comments:
By checking this box and typing my name below, I am electronically signing my name
Volunteer signature*
Date*

MonthDayYear
Date
Call with any situation that requires immediate attention, 272-0212 Submit this contact report online within a week of the visit
Should be Empty: