Therapy Animal Team Visit Log (Facility-Based)

Facility/Campus: [Facility or campus name]

Program Name: [Program name]

Visit Date: [YYYY-MM-DD]

Start Time: [Start time]

End Time: [End time]

Duration: [Calculated or entered duration]

Visit Type: [Scheduled rounds / Requested bedside visit / Group activity/event / Staff support/wellness / Other]

Visit Status: [Completed as planned / Completed with modifications / Canceled/aborted]

Cancellation/Modification Reason: [Reason for cancellation or modification, if applicable] (Include only if visit status is "Canceled/aborted" or "Completed with modifications")

Therapy Animal Team Identification

(Repeat this block for each participating team. Do not include any patient identifiers anywhere in this log.)

Handler Name: [Handler full name]

Handler Role: [Volunteer / Staff / Contractor]

Handler ID/Badge Number: [ID or badge number]

Animal Name: [Animal name]

Species: [Dog / Cat / Rabbit / Other]

Animal ID/Registration Number: [Program-issued ID or registry number]

Certifying Organization: [Name of certifying organization] (Include if applicable)

Escort/Liaison Name: [Escort or liaison name] (Include if required by facility)

Unit Contact: [Charge nurse/manager who coordinated the visit]

Visit Locations and Movement Log

(Add one row per location/area visited or attempted. Do not include patient names; use location/room numbers or general area only. This log supports contact tracing for infection prevention.)

Location/Unit	Room or Area	Time In	Time Out	Encounter Mode	Staff Clearance Obtained
[Unit name/number]	[Room number or area description]	[HH:MM]	[HH:MM]	[Bedside / Hallway / Dayroom / Group / Staff-only / Attempted—declined: reason]	[Yes / No / NA]

Participants Served

(Use aggregate counts only; do not include patient-level details.)

Patients Engaged: [Number] (Note if estimated)

Family/Visitors Engaged: [Number]

Staff Engaged: [Number]

Group Sessions: [Number and type, e.g., pediatric playroom, rehab group, staff huddle] (Include if applicable)

Unit Population Served: [e.g., Pediatrics / Oncology / Rehab / General medical] (Optional; unit-level only)

Purpose of Visit

Purpose Categories: [Comfort/emotional support / Distraction during hospitalization or procedure wait / Motivation/engagement / Socialization/connection / Staff morale/stress reduction / Bereavement/compassion support / Other] (Select all that apply)

Brief Purpose Statement: [1–2 sentence description of visit intent and setting] (Do not imply clinical therapeutic intervention unless this was a credentialed, goal-directed therapy service with separate clinical documentation.)

Safety and Infection Control Attestations

(All items require a response. Provide a brief comment for any "No" response. Use NA only if clearly not applicable.)

Pre-Visit Animal Screening

• Animal appears healthy today (no vomiting, diarrhea, cough, lethargy): [Yes / No / NA] [Comment if No]
• No open wounds, skin lesions, or visible parasites: [Yes / No / NA] [Comment if No]
• Vaccinations and parasite prevention current per program requirements: [Yes / No / NA] [Comment if No]
• Animal clean and well-groomed: [Yes / No / NA] [Comment if No]
• Animal reliably housebroken: [Yes / No / NA] [Comment if No]
• Diet restrictions met per facility policy: [Yes / No / NA] [Comment if No]
• Animal under appropriate control (leash/harness): [Yes / No / NA] [Comment if No]

Pre-Visit Handler Screening

• Handler appears well and can comply with infection prevention practices: [Yes / No / NA] [Comment if No]
• Handler has completed required facility orientation: [Yes / No / NA] [Comment if No]
• Handler has hand hygiene supplies available: [Yes / No / NA] [Comment if No]

Point-of-Care Screening

• Unit staff confirmed patient/area eligibility for animal visitation: [Yes / No / NA] [Comment if No]
• No entry to restricted areas (ICU, isolation rooms, nurseries, or facility-defined restricted zones): [Yes / No / NA] [Comment if No]
• Allergies, phobias, or cultural/religious concerns respected for declined visits: [Yes / No / NA] [Comment if No]

During-Visit Infection Prevention

• Hand hygiene performed/offered before and after animal contact: [Yes / No / NA] [Comment if No]
• Contact with animal saliva prevented: [Yes / No / NA] [Comment if No]
• Animal contact with invasive devices, open wounds, or dressings prevented: [Yes / No / NA] [Comment if No]
• Single-patient barrier used if animal placed on bed or lap: [Yes / No / NA] [Comment if No]
• Treat handling controlled by handler with appropriate hand hygiene: [Yes / No / NA] [Comment if No]

Environmental/Waste

• Any animal waste incident? [Yes / No] (If Yes: Location: [Unit/area]; Cleanup actions: [Actions taken]; Notifications: [Personnel notified])
• Post-visit cleaning needed beyond routine housekeeping? [Yes / No] (If Yes: [Explanation])

Observations and Outcomes

(Document observable engagement, brief de-identified feedback, and operational notes. Avoid clinical assessments or treatment claims.)

• [Observable engagement and participant responses]
• [Participant or staff feedback, de-identified]
• [Operational notes: timing, environmental factors, or competing activities]

Exceptions, Declines, and Barriers

(Include only if applicable)

• Declined Visits: [Count and reasons: patient declined (fear/allergy concern/cultural concern/unspecified); staff declined (procedure in progress/patient resting/isolation precautions/other)]
• Access Limitations Encountered: [e.g., restricted area signage, environmental hazards]
• Modifications Made: [e.g., hallway-only interactions, staff-only visit, relocated group session]

Incident Reporting

Any incidents or adverse events? [Yes / No]

(If No, document: "No incidents to report.")

(If Yes, complete the following:)

• Incident Type: [Bite / Scratch / Fall/trip / Contamination / Equipment damage / Near-miss / Behavioral stress requiring termination / Other]
• Location: [Unit/room/area]
• Persons Involved: [Describe by role only: patient/staff/visitor]
• Immediate Actions: [Actions taken]
• Notifications Made: [Unit leadership / Infection prevention / Program coordinator / Risk/safety / Employee health / Other]
• Disposition: [Continued visit / Terminated visit / Animal removed from service pending evaluation]

Follow-Up Actions

(Include only if applicable)

• [Follow-up actions needed: update unit eligibility list, handler coaching/training, animal health/behavior reevaluation, policy clarification with infection prevention, return visit requests]

Attestation and Sign-Off

Handler Attestation: I certify that the above information is accurate and that I adhered to program policies and infection prevention requirements during this visit.

Handler Name: [Name] Signature: [Signature] Date: [YYYY-MM-DD] Time: [HH:MM]

Facility Staff Verification: I confirm the visit locations and completion as documented.

Staff Liaison Name: [Name] Role: [Role] Signature: [Signature] Date: [YYYY-MM-DD]

Time of Documentation: [HH:MM] (Include if documentation completed after visit. Corrections should be made as dated addenda rather than overwrites.)