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 Number (if known)
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?
 Yes No
Are you requesting mileage reimbursement?
 Yes No

Entry #1
Date

Code

Time Spent (minutes)

Travel Time (minutes)

Miles

Entry #2
Date

Code

Time Spent (minutes)

Travel Time (minutes)

Miles

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