REAL Services

In the News:

AARP Applauds Senate Passage of Historic Health Reform Package
Will help Medicare patients by closing the "doughnut hole" and strengthening laws against fraud, waste, and abuse.

Health Care Reform

BBB Alerts Consumers about U.S. Census Workers: Be Cooperative, But Cautious!

Nursing Facility Friendly Visitor Reporting Form

Name:
Month Completed:
Email:
Facility :

In the 'Notes' below, please specify the dates, times, and activities that you did. If you visited with a specific resident, please note their name below.

Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:
Date Resident Start Time End Time Total Time		Activity/Job Duties:

Volunteer Signature

(My signature, electronic/typed or original, entered here attests to the accuracy of this information.)

If you have any questions or concerns about your hours or your volunteer assignment, please contact the volunteer dept at volunteer@realservices.org.

REAL Services 1151 S. Michigan Street South Bend, IN 46601 Fax: 574-284-2691 Office Locations List of Holidays our Offices are closed	The Promise of Community Action Community Action changes people’s lives, embodies the spirit of hope, improves communities, and makes America a better place to live. We care about the entire community, and we are dedicated to helping people help themselves and each other. REAL Services, believing in the dignity of all people, will provide services to eligible persons without regard to race, creed, sex, or national origin.
Web site last updated on April 4, 2011	To Report elder abuse: Adult Protective Services