Visit Report

Visiting Nurse Association of Greater St. Louis
Visit-A-Bit Program
PURPOSE: To report information about your volunteer visit with a senior participant assigned to you by the Visit-A-Bit Program.
Visit-A-Bit Program Conditions of Submission of Information via This Electronic Form Regarding Senior Participant Assigned to Volunteer
As a volunteer in Visiting Nurse Association’s Visit-A-Bit program, you are responsible and will be held accountable for the information you are submitting regarding the senior participant assigned to you in the Visit-A-Bit program.
Definitions:
“Volunteer” refers to the individual assigned to visit with a senior participant in the program.
“Senior Participant” refers to an individual enrolled into the Visit-A-Bit program.

“VNA” refers to Visiting Nurse Association of Greater St. Louis.
“Visit-A-Bit” refers to the program developed by VNA to address senior adult loneliness.
Conditions for Submission of Contact Report Information To VNA
You agree when completing the form that these conditions must be followed in submitting contact report information regarding the senior participant assigned to you.
1. Enter all required information, including your assigned VOLUNTEER NUMBER and SENIOR NUMBER. If you do not know your volunteer number or senior number, contact the Visit-A-Bit Program.
2. UNDER NO CIRCUMSTANCES should any information regarding the senior participant’s health or their personal health information be submitted on this form. This includes but not limited to: name, address, phone number, date of birth or health condition. For a full list of words and phrases that are not permitted, click here.
3. In the event you need to report a senior participant’s health, their personal health information, or any personal information, call the Visit-A-Bit program office at 314-918-7171.
4. Answer questions and report the facts of your visit with the senior participant.
5. Information submitted regarding the senior participant should not be shared with anyone outside of Visit-A-Bit.
Terms of Use.*
You understand if you do not follow the conditions as stated in this document for submission of information about a senior in the Visit-A-Bit program, you may be terminated as a volunteer of the program. You may also be held liable for any information submitted that does not adhere to the conditions as stated in this document or set forth by the Visit-A-Bit Program. If you have any questions, call the Visit-A-Bit office at 314-918-7171.
I accept the terms of use

Basic Visit Information
Volunteer ID #*
Senior ID #*
Date of Visit*
MM slash DD slash YYYY
Visit Start Time*
: Hours
Minutes
AM/PM
Visit End Time*
: Hours
Minutes
AM/PM
Type of Contact*
Call
Visit

My next contact will be a:*
Visit
Call
My next contact will be on:*
MM slash DD slash YYYY
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Visiting Nurse Association of Greater St. Louis

Visiting Nurse Association of Greater St. Louis

DO NOT VISIT IN-PERSON.