TOUCH – Monthly Visit Log

This form will be used in consideration for re-certification for ranking changes, as well as recording the active status of you and your dog.

Date*
MM slash DD slash YYYY
Handler name*
Dog name*
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
Date of visit Hours # People T/P/H Facility
# People = ALL direct interaction between Handler and/or dog with patient, staff or visitors
Additional visits not recorded above
Feedback
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Name
This field is for validation purposes and should be left unchanged.

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