VISITATION ACTIVITY REPORT
Volunteers Name
First Name
Last Name
Facility Visited
Date
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
1. Anything interesting while on your visit?
2. Anything that needs addressing at the facility?
3. Any Special Moments?
4. Comments and recommendations:
5. How many Clients, Staff and Visitors? Visited today.
6. Rooms Visited: Room Number or Community room name
7. Overall, how would you rate the facility and staff?
Very Unsatisfied
Unsatisfied
Neither Satisfied
nor
Unsatisfied
Satisfied
Very Satisfied
Service Quality
Cleanliness
Responsiveness
Friendliness
Helpful
Submit
Should be Empty: