In Person Visit Form Volunteer Opportunities Volunteer Application Volunteers Portal Login Volunteer Activity Reports Does anyone in the home have any of these symptoms (check all that apply)?(Required) Fever Muscle aches Headaches New loss of taste or smell Chills Nausea/Vomiting/Diarrhea Sore throat Cough Shortness of breath/Difficulty breathing None of the above Does anyone present in the household have contact with a laboratory-confirmed COVID-19 individual in the past 14 days?(Required)Choose Yes/NoYesNoHas anyone in the home tested positive for COVID-19 in the past 14 days?(Required)Choose Yes/NoYesNoIf there are no symptoms and the answers to the final two questions are No, proceed with visit and wear surgical mask/face shield. If any COVID-19 screening answers are "yes", please cancel visit and note “Not made” in your visit note. Contact Tidewell immediately if the visit is not made.Volunteer's Full Name(Required) First Last Volunteer's ID Number(Required) County(Required)Choose CountyManateeSarasotaCharlotteDesotoDate of Service(Required) MM slash DD slash YYYY Patient's Name(Required) Patient ID Number(Required) Start Time(Required) Hours : Minutes AM PM AM/PM End Time(Required) Hours : Minutes AM PM AM/PM Family Involvement(Required)Choose Yes/NoYesNoVolunteer Services Role(Required) Please type in your Volunteer Services RoleTask Completed and/or ObservationsCommentsThis field is for validation purposes and should be left unchanged. Δ
