PFE PROGRAM VISIT REFLECTION
This form is to be used by students to reflection on time spent with their PFE Program Senior Mentors
Person Submitting *
Your Assigned PFE ID *
Your answer
Date of Visit *
MM
/
DD
/
YYYY
Companionship Activities you perform with your Senior Mentor
Time is in quarter hour increments (15 mins = .25 of an hour). Please do your best to estimate (we just need your best guess of how much time you spent performing the different activities.)
0.0
.25
.50
.75
1.00
Assisting with Technology
Playing Games/Puzzles
Performing or learning Arts/Crafts/Music
Looking thru & organizing Pictures/Scrapbook
Talking/Sharing Stories
Walking/Exercising
Receiving help with Homework
Working on a Hobby or DIY project
Providing Person Care such as painting nails, hand massages
Other (Provide details below)
Chore Activities your perform with your Senior Mentor
Time is in quarter hour increments (15 mins = .25 of an hour). Please do your best to estimate (we just need your best guess of how much time you spent performing the different activities.)
0.0
.25
.50
.75
1.00
Baking/Preparing Meals
Organizing rooms, closets or cabinets
Bathroom/Kitchen cleaning
Laundry (wash, dry, fold)/changing sheets/towels
Dusting/Sweeping/Vacuuming
Outdoor maintenance/Gardening/Yard work
Helping with pets (cleaning cages/walking)
Other (Provide details below)
Total Time Spent *
Number of Senior Mentors Visited Today and Setting.
1
2
Nursing Home
Assisted Living
Senior Mentor's Home
Getting to know your Senior Mentor Project
Your answer
Details of Visit *
Include Senior Mentor name. Expand on the activities you performed with your Senior Mentor. For example: What was the story you read and what was your and your Senior Mentor's reaction to the story? Did you learn something interesting about your Senior Mentor such as a previous career or experience? This will require you to write at least two sentences.
Your answer
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