Community Caregivers

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Activity Log

Instructions: After each visit, please complete Activity Tracking Log for only one consumer at a time and include only one name on each form. Submit to Community Caregivers Volunteer Coordinator using the form below.

*required

CSN VOLUNTEER NAME:

Volunteer's E-mail

* (required for processing)

Start Date:

End Date:

Consumer Name:

Consumer address:

Date of Contact	Type of Contact HV-Home Visit P- Phone Call O-Other (e.g. in hospital, at doctors office, etc.)	Length of Visit/Call (Report in ¼-hour increments, e.g. 0.5, .75, 1, 1.25, etc.)	Type(s) of Activity Include all applicable #’s from the Activity List below	Comments About The Contact?	Miles Driven

Essential Coaching Tasks:
1. Encouraged use of medication reminders
2. Encouraged and assisted with completion of Personal Health Record
3. Encouraged scheduling and compliance with M.D. appointment (s)
4. Enhanced health literacy skills– e.g. reviewed diagnosis packets, Red Flags chart, etc.

Secondary Support Tasks:
5. Facilitated contact with NY Connects for information on available supports and services
6. Facilitated contact with The Eddy R.N. Coach for information or assistance
7. Facilitated contact with Caregiver Support Programs
8. Facilitated transportation to M.D. appointment (s)
9. Facilitated or assisted with grocery shopping
10. Facilitated or assisted with accessing prescribed medications
11. Facilitated or assisted with accessing or using equipment or assistive technology (e.g. pill boxes, medication check lists, automatic medication dispensers, etc
12. Facilitated or assisted with reading mail or other household paperwork

Assistance Tasks (only when necessary):
13. Provided transportation to M.D. appointment (s)
14. Provided transportation to non-medical appointments
15. Provided general companionship and support (e.g. checking in)
16. Other (Please Explain in "Comments" column above, or fill out Comment Form to explain in more detail)

*Please print this form for your records BEFORE hitting the “Submit” button*

2021 Western Avenue, Suite 104, Albany, New York 12203 PH: 518.456.2898 info@CommunityCaregivers.org

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