Community Visitors Scheme Feedback

Name of Volunteer:*

First Name Last Name

Phone Number:

Name/s of volunteer partners*

Write N/A if not applicable

I volunteer as part of*

Ohel Chana YLiV Yeshivah Gedolah DaMinyan None of the Above

Name of senior currently visiting:

Name of aged care home*

write N/A if not applicable

Date of visit and time arrived:*

Day Month Year

Hour Minutes

Time left:*

Hour Minutes

Type of Visit*

Group One-on-one Phone Call Email

How many people did you visit?*

Please outline any highlights of your visit

I feel there is adequate communication between myself and the senior I am visiting:

0 1 2 3 4 5

The time of my visits fit with this person's daily schedule:

0 1 2 3 4 5

I feel I make a difference to this person's life:

0 1 2 3 4 5

I feel there is more we can do for this person:

0 1 2 3 4 5

I feel I have gained by visiting the elderly:

0 1 2 3 4 5

I enjoy giving of my time to visit the elderly:

0 1 2 3 4 5

Please elaborate on any of your answers and add any further comments:

Community Visitor Scheme Feedback