Volunteer Grief Mentor Log sheet

For ACCESS Volunteer Grief Mentors only:
Please fill out this form after each contact with the client you are mentoring or after the 3rd unsuccessful attempt to make contact.

Click here to download the PDF version of the Log Sheet.

Terms of Volunteer Grief Mentoring

    Mentoring Date:

    Your Name (required):

    Phone:

    Your Email (required):

    Client Information:

    Client/Caller's Name:

    Phone:

    Best Time(s) to Call:

    Client Email:

    Prefers to be contacted by:

    Email communication is acceptable, but communicating by telephone is a more effective form of mentoring. If possible, try to set up a phone appointment with the person you are mentoring.

    Name(s) of loved One(s):

    Relationship / Age(s):

    Air Carrier / Flight Number:

    Call / Email Log:

    Date / Time:

    Attempted Contact by:
    PhoneEmail

    Notes:

    Date / Time:

    Attempted Contact by:
    PhoneEmail

    Notes:

    Date/Time:

    Attempted Contact by:
    PhoneEmail

    Notes:

    Summary of Client / Caller's Response

    Thoughts / Feelings:

    What was the focus of the call?

    His/Her available support systems:

    Your Assessment:
    Doing as well as can be expected
    Concerned about his/her mental state (if so, explain below)

    Additional Comments or Concerns:

    Your Next Step:
    Follow up callFollow up email
    To be made on:

    Information / Referral Requested (explain):

    Thank you for being a Volunteer Grief Mentor.
    You are the heart of ACCESS!

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    Families We Have Helped:

    Below are some of the air disasters that we have responded to:
    Private Plane - 9/26/12
    Rockingham County, VA
    Private Plane - 2/27/11
    Abu Dhabi
    Private Plane - 12/22/10
    Barrington, NY
    Private Plane - 7/17/10
    South Portland, ME
    Air India Express 812 - 5/22/10
    Mangalore, India
    Afriqiyah Airways 8U771- 5/12/10
    Tripoli, Libya
    Ethiopian Airlines 409 - 1/25/10
    Off of Na'ameh, Lebanon
    Air France Flight 447 - 6/1/09
    Atlantic Ocean
    Turkish Airlines Flight 1951 - 2/25/09
    Amsterdam Airport Schiphol
    Continental Flight 3407 - 2/12/09
    Clarence Center, NY
    US Airways Flight 1549 - 1/15/09
    Hudson River, NY
    Aeroflot Flight 821 - 9/14/08
    Perm, Russia
    Spanair JK 5022 - 8/20/08
    Madrid, Spain
    TAM Airways JJ 3054 - 7/17/07
    São Paulo, Brazil
    Comair Flight 5191 - 8/27/06
    Lexington, KY
    Airbus A320-211 - 5/3/06
    Off Sochi, Russia
    Bellview Airlines - 10/23/05
    Nigeria
    West Caribbean Airways 708 - 8/16/05
    Machiques, Venezuela
    Air France Flight 358 - 8/2/05
    Ontario, Canada
    Kam Air Flight 904 - 2/3/05
    Pamir Mountains, Afghanistan
    Corporate Airlines 5966 - 10/19/04
    Pettis Township, MO
    Kish Airlines Flight 1770 - 2/10/04
    United Arab Emirates
    Georgian Express Flight 126 - 1/17/04
    Ontario, Canada
    Flash Airlines 604 - 1/3/04

    Red Sea

    Turkish Airlines 634 - 1/8/03

    Diyarbakır Airport, Turkey

    US Airways Express/Air Midwest Flight 5481 - 1/8/03

    Charlotte, NC

    American Flight 587 - 11/12/01

    Queens, NY

    The events of September 11, 2001

    Private Plane - 12/3/00
    Milltown, WI
    Singapore Airlines 006 - 10/31/00

    Chiang Kai-shek Internat'l Airport

    Gulf Air Bus A320 - 8/23/00

    Persian Gulf, Bahrain

    Air France Concorde 4590 - 7/25/00

    Gonesse, France

    Alaska Airlines 261 - 1/31/00

    Pacific Ocean

    Egypt Air 990 - 10/31/99

    Atlantic Ocean

    American Airlines 1420 - 6/1/99

    Little Rock, AR

    Swissair 111 - 9/2/98

    Atlantic Ocean

    Private Plane - 8/4/98
    Phillips, WI
    TWA 800 - 7/17/96

    US Air 427 9/8/94

    Allegheny County, PA

    Long Island, NY

    Pan Am 103 - 12/21/88

    Lockerbie, Scotland

    TWA/United Airlines - Mid-Air Collision- 12/16/1960
    Brooklyn & Staten Island, NY
    and hundreds of other private, commercial and military air disasters

    See Full List