Visitation Coordinator Report

In order for Support Dogs, Inc. to ensure the effectiveness of the TOUCH Program in those facilities we serve, we ask that you comlete the following report on a montly basis. The information you provide will help us evaluate the program and provide information for our funders - funders who continue to help us provide this program in local facilities.  We understand that it is not always possible to gather spcifies, so please estimate the best way you can.

  • Date
  • Reporting Cordinator
  • Report Month/Year
  • Facility
  • Primary Facility Contract
  • Phone

Type Of Facility:
Assisted Living Lock Down Unit/Children Skilled Nursing Unit
Behavioral Unit/Adult Long Term Care Special Needs Day Care/Adult
Behavioral Unit Children Library Locations* Special Needs Day Care/Children
Hospital Rehab Unit Psyciatric Hospital Special School District Location*
Lock Down Unit/Adult Rehabilitation Unit School OT/PT Classrooms(s)
* These locations are Paws For Reading locations only.

Facility Demographics:
  • Primary:WomenMenBothAdultsTeenagers/Young AdultsChildren
  • Age Range:
  • Total number of patients/residents visited for the month:
  • Total number of staff members visited:
  • Total number of family and non-family individual visited:

Visitation Schedule:
  • Regular visitation schedule:
  • Group assembly/entrance location:
  • Does your facility need teams? If yes, how many?
TOUCH Teams presents:
  • HandlerDog
  • HandlerDog
  • HandlerDog
  • HandlerDog
  • HandlerDog
  • HandlerDog
  • HandlerDog

  • Please note any comments that you would like to share from the patients/residents during the visits.
  • Were there any unusual occurrences or incidents during the visit? If yes, please describe here.
    If necessary you and/or the teams involved will also need to completed an Incident Report Form.
    Teams involved

    Behavior/Incident

  • Teams involved

    Behavior/Incident