Volunteer Feedback Form

Volunteer Mentor: * Matched With: * Date: (mm/dd/yyyy) * Date: (mm/dd/yyyy) Date Method of Contact: * Phone E-Mail Specify your own value:     Date(s) of Contact: * Length of Contact: * Patient's Coping with Cancer Diagnosis: * Poor Fair Okay Excellent Where there any issues that need further examining (counseling, financial, family, insurance)? Do you plan to call the person again or maintain any further contact? * Yes No As Needed Overall Match was: * Poor Fair Okay Good Excellent Did you have a 4th Angel: Yes No How did you hear of our program: Brochure Social Worker Internet Nurse Physician Radio/TV/Newspaper Cancer Organization Family/Friends Specify your own value:     Are you interested in additional 4th Angel Volunteer opportunities (assist with mailings, birthday cards for mentors, etc). Yes No Any recommendations for volunteer opportunities: We also have a 4th Angel Caregiver Mentor Program. Would your caregiver (spouse, child, parent, sibling, partner) be interested in becoming a Caregiver Mentor? Yes No If yes, please provide their contact information: Recommendations/Questions for the 4th Angel Program Coordinator.