Today's date: 

Volunteer Name: 

Volunteer Email Address: 

Elder Name: 

Please indicate which year/quarter this report is for:

Year: 

Quarter:
 1Q (Jan-March)
 2Q (April-June)
 3Q (July-Sept)
 4Q (Oct-Dec)

* Please round up the time and indicate it in 15 minute increments.

In Person Visits

Number: 

Hours: 

Notes:


Phone Visits

Number: 

Hours: 

Minutes: 

Notes:


Phone Reassurance

Number: 

Hours or Frequency: 

Notes:

Direct Service

While ElderFriends is not a chore or errand service, we acknowledge that you may engage in many types of assistance to your elder friend in the course of developing your friendship. Tracking these activities helps us note trends in the needs of our participants and ensures that we can provide you the best possible support.

If you helped your elder friend with any activities of daily living please mark the boxes below, along with the approximate number of times you helped with each activity during this quarter. For general categories, please indicate specific activity in the notes section.

 Household chores (e.g. laundry, dishes, vacuuming, etc.)

Approximate number of times: 

Notes:



 Food Shopping

Approximate number of times: 

Notes:



 Clothes Shopping

Approximate number of times: 

Notes:



 General Shopping

Approximate number of times: 

Notes:



 Pharmacy pick-up

Approximate number of times: 

Notes:



 Errands (e.g. bank, post office, dry cleaning, etc.)

Approximate number of times: 

Notes:



 Home repair and maintenance (e.g. repair doorknob, install showerhead, etc.)

Approximate number of times: 

Notes:



 Yard work

Approximate number of times: 

Notes:



 Help accessing community resources (i.e.: research housing options, help access public assistance, help with phone calls or applications, etc.)

Approximate number of times: 

Notes:



 Reading Mail

Approximate number of times: 

Notes:



 Reviewing bills/filling out checks

Approximate number of times: 

Notes:



 Provide transportation to medical/dental appointments

Approximate number of times: 

Notes:



 Accompany to medical/dental appointments

Approximate number of times: 

Notes:



 General Transportation (i.e.: to social events, church, etc.)

Approximate number of times: 

Notes:



 Intervene in medical emergency (e.g. call 911, check in during heat wave, etc.)

Approximate number of times: 

Notes:



 Report abuse, neglect, exploitation or other concerns

Approximate number of times: 

Notes:



Personal Care (please be specific regarding the following):

 Bathing

Approximate number of times: 

Notes:



 Toileting

Approximate number of times: 

Notes:



 Cooking

Approximate number of times: 

Notes:



 Dressing

Approximate number of times: 

Notes:



 Hair Care

Approximate number of times: 

Notes:



 Nail Care

Approximate number of times: 

Notes:



 Other personal care

Approximate number of times: 

Notes:



 Other direct service (e.g. moving, pet care, vehicle maintenance)

Approximate number of times: 

Notes:

Please note any address changes here: