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Office of State Guardian
Ward Visit Form
Required
indicates required field
Volunteer Name
Volunteer Email
Ward Name
Facility
Date of Visit
Visit Location
Length of Visit
(in minutes, including time spent with staff and reviewing records)
Appearance of the Ward
(Check all that apply)
Neat
Unkempt
Clean
Dirty/Stained Clothes
Dressed Inappropriately
Dressed Appropriately
Ambulates without assistance
Ambulates with cane
Ambulates with walker
Ambulates with wheelchair
Mood of the ward
(Check all that apply)
Appropriate
Angry/Hostile
Troubled, Sad, or Depressed
Thought Content Inappropriate
Short Attention Span
Unable To Determine
Interaction Active
Interaction Passive
Did the ward asknowledge your presence?
Yes
No
Was the ward doing any Activities?
Yes
No
Was the ward satisfied with the staff?
Yes
No
Was the staff available to answer questions?
Yes
No
Was the ward satisfied with the care?
Yes
No
Please provide a brief narrative describing your visit.
(Including descriptions to your answers above. What did you and your ward do? What did you talk about? Any specific concerns of progresses?) Please type in all lower case for data entry purposes
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