Volunteers – Please fill out your timesheet below and click “Send” to submit it to the HospiceCare volunteer department. This form allows you to send 2 entries at a time. If you need to submit more entries, you may submit multiple sheets. Codes can be referred to at the bottom of the page.

*IMPORTANT* Due to HIPAA regulations, please do not use any patient’s last name on this form.

    *indicates a required field
    Volunteer Name*
    Volunteer Phone*
    Patient First Name and Last Initial ONLY
    Patient # (if known)
    If a medication was delivered, has the Medication Delivery Form for controlled substances been mailed?
    YesNo
    Are you requesting mileage reimbursement?
    YesNo

    Entry #1
    Date

    Code

    Time Spent (minutes)

    Time In

    Time Out

    Travel Time (Round Trip)

    Miles (Round Trip)

    Comments regarding the nature of the work performed *Required

    Entry #2
    Date

    Code

    Time Spent (minutes)

    Time In

    Time Out

    Travel Time (Round Trip)

    Miles (Round Trip)

    Comments regarding the nature of the work performed*Required

    Please click the box below to show you are a person: