Scheme Code: SUH

Volunteer Name:

Month/Year:

HS Family No:

Vol No:

Planned visit date

Visit took place?

Y/N

A Reason visit did not take place*

Code 1-6

B Who did you see at home when you visited?

Visit start time

Visit end

times

C Activities*

 

 

 

Code 1 - 5

D Services*

Telephone/

Text contact instead of visit? Yes/No

D Use code to indicate service*

E Role with service

Code 1 -6

Date of family using service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

Reason visit did not take place (select one only)

B

Who did you see at home  (incl all there)

E

Role related to service use –see D (select all appropriate)

1

Parent cancelled

M

Mum

1

Signposting the service, gave address, contact details etc

2

Parent rearranged

D

Dad

2

Transport – provided transport to the appointment

3

Volunteer cancelled

C1

Oldest child

3

Accompanying – went to the appointment with the family

4

Volunteer rearranged

C2

Second child (continue as nec, C3, C4 etc)

4

Discussed information about the service prior to or following use

5

Parent not at home

O

Other (specify eg neighbour, relative etc)

5

Looked after children while parents used service

6

Other (specify)

 

 

6

Other (specify)

C

ACTIVITIES (select all appropriate)

1

Practical support (eg budgeting, telephone calls, cooking, shopping, improving hygiene, help with routine/behaviour, writing letters, respite, took family out)

2

Activities with children (eg playing with children, reading, listening to children, fun outdoor activity; help with routine/activity)

3

Emotional support (listening, empathising)

4

Support to use other service (eg signposting accompanying, discussing prior to/after appointment)

5

Other (specify)

D

SERVICES

1

Family G.P.

10

Housing advice/support

19

Religious organisations

2

Health Visitor

11

Benefits Dept

20

Free eye sight tests

3

Social worker

12

Speech & Language

21

Attended appointments

4

Mother & Baby clinic

13

CPN/Mental Health

22

Dental check

5

Children’s Centre (Sure Start)

14

CAMHS

23

Up to date vaccination

6

Job Centre Plus

15

Adult education

24

Other voluntary service

7

CAB

16

Received books free from Bookstart

25

Other statutory service

8

Debt counselling

17

Family joined local library

26

Internet access

9

Turn2Us online &/or helpline services

18

Toddler group/Nursery/School

27

Parenting programme

                                   

 

Volunteer structured diary continued

 

Life Events

Has the family had a recent life event, during support or within 1 year before the start of support?  If yes, please state when and describe briefly.

Life Event

Date

Describe

1. Recent bereavement

 

 

2. Change in employment status

 

3. Reduction in income(e.g. benefits, tax credits, salary)

 

4. Change in relationship, ie separation, new partner/marriage

 

5. Serious Illness – parent/child?

 

6. New birth

 

7. A&E visit – adult/children?

 

8. Becoming a carer

 

9. Change in housing

 

10. Change in Immigration status

 

11. Other (specify)

 

 

Other volunteer comments: Please add any additional information:

(Include here any supportive telephone call or text (1); emergency, eg hosp (2); outing (3); celebration (4); other (5)

 

  

 

 

 

 

 

 

 

 

 

 

Volunteer Structured Diary Sheet

 

This form must be completed after each visit or contact with the family. It should be returned to the Home-Start office each month together with your expense form. It is important that the scheme has a record of contact with the family, so if you are unable to return the form to the office, then you should give the information to your organiser/co-ordinator over the phone.

 

Please use the coding system to complete each column with an *.  Note there may be more than one activity or service for each visit.  You may also play more than one role in supporting families with each service; please ensure the roles you play are noted alongside each service.   For example, you may accompany your family on an appointment (3) then you may discuss the information from the appointment with them afterwards (4).  Or you may signpost them to a service (1) and discuss how they could best use the service prior to an appointment (4).

 

If you have any question please call the office.