Appendix E.1 – Sample AmeriCorps Seniors Volunteer in SCP Assignment Plan

# Appendix E.1 – Sample AmeriCorps Seniors Volunteer in SCP Assignment Plan

**Assignment Plan**
Instructions:  It is a federal requirement that all AmeriCorps Seniors volunteer in SCP have an Assignment Plan for the clients with whom they are assigned to work.  The clients they are assigned to must have documented a special need – defined as one or more physical, emotional, or mental health limitations – and be in need of assistance to maintain their highest level of independent living.  The AmeriCorps Seniors volunteer in SCP is assigned to your organization to provide direct services to one or more eligible clients that result in person-to person supportive relationships with each client served. 

Please complete all sections, documenting the client’s needs, the activities you want the volunteer to perform, and the desired results of those activities.  The completed assignment plan becomes the volunteer’s “job description.”  Please review it with the volunteer to ensure that the required activities and the desired outcomes are understood.  Obtain all signatures indicated on page 2 and send to the AmeriCorps Seniors SCP project office for approval.   

The AmeriCorps Seniors Senior Companion Program recognizes and respects the confidentiality of all of the clients involved in the program.  Please be assured that all of the information that you provide will only be used in aggregate and no specific client will be identified.

AmeriCorps Seniors Volunteer: _______________________________________________________  

Volunteer Station/Site:  	__________________________________________________________ 

Supervisor’s Name:  	___________________________________phone/email________________

Period this plan covers: 	__________________________________________________________

**Client Information:**

Client’s Name: ___________________________________________________________________

Date of Birth: ____/_____/________

Male /Female 

Client is living in their own home?  Yes or  No  

Client is living with family?  Yes  No

Activity will take place in home?  or in a day program  ?  

Client is a Veteran?  Yes  No

Hospice Care?  Yes  No

Respite?   Yes  No

**Client’s Needs and Health Assessment:**

****Blind/Visually Impaired                		****Homebound/Living Alone    	****Chronic Disability 

****Alzheimer’s or other chronic disease    	****Substance Abuse	             	****Terminal Illness      

****Mental Health Related Issue                 	****Respite            

****Other, Describe:**** _________________________________________________________________

**Activities planned with assigned client**: Describe below the activities the AmeriCorps Seniors volunteer in SCP will perform**(Please check all that apply)**

 Assist with meal prep and nutrition	 Transportation      			 Walking      

 Light Housekeeping	 	 Help pay bills				 Assist with dressing 

 Accompany shopping		 Assist with ADL     			 Doctor’s Visits       

 Accompany on errands	     	 Assist with medication   		 Companionship  

 Assist with reading or writing

Other _________________________________________________________________________

Description ________________________________________________________________________ 

__________________________________________________________________________________

__________________________________________________________________________________

**Schedule- Day/Time:**

Sun:____________________ Mon: ___________________  Tues: ___________________  

Wed. _________________  Thurs: ________________  Fri: ______________  Sat:______________

**Expected Outcomes.**How do you expect that the client and, in the case of respite care, caregivers will benefit for the AmeriCorps Seniors volunteer in SCP’s activities?  Will the client...

 Feel less lonely and isolated?          	 Be more socially engaged?        

 Remain living in own home?         	 Receive required medications on schedule?        

 Benefit from improved nutrition?        

 Be able to carry out activities of daily living such as eating, dressing, using the bathroom? 

 Will caregivers be able to go to work/attend to personal affairs?

Other _________________________________________________________________________

Description _________________________________________________________________________

           _________________________________________________________________________

**Signatures:**

**I accept this assignment plan:**

_____________________________________		____________________

Signature:  AmeriCorps Seniors Volunteer		Date

__________________________________	   	___________________

Signature:  Volunteer Station Representative		Date

**I approve this assignment plan:**

______________________________________		____________________

Signature:  AmeriCorps Seniors SCP Director		Date

**Assignment Plan for a Senior Companion Leader**

Instructions:  AmeriCorps Seniors volunteer leaders in SCP with special skills or demonstrated leadership ability may perform indirect service, such as assisting newer AmeriCorps Seniors volunteers in SCP in performing their assignments or coordinating the activities of other AmeriCorps Seniors volunteer in SCP. It is a federal requirement that all AmeriCorps Seniors volunteer leaders in SCP have an assignment plan that identifies the roles and activities of the AmeriCorps Seniors volunteer leaders in SCP and the expected outcomes. 

Please complete all sections, documenting the role and activities you want the volunteer to perform, and the desired results of those activities. The completed assignment plan becomes the volunteer’s “job description.” Please review it with the volunteer to ensure that the required activities and the desired outcomes are understood. Obtain all signatures indicated on page 2 and send to the AmeriCorps Seniors SCP project office for approval.   

AmeriCorps Seniors Volunteer: ____________________________________________________________

Service Schedule:  _____________________________________________________________

Volunteer Station/Site:  __________________________________________________________ 

Supervisor’s Name:  _____________________________________________________________

Period this plan covers: __________________________________________________________

A. **Activities planned**. Describe below the activities the Senior Companion leader will perform (For example, will the volunteer coach new Senior Companions in performing their work? Coordinate scheduling of other Senior Companions? Deliver training?):**

**C.  Expected Outcomes.**What are the expected results of the AmeriCorps Seniors volunteer leaders in SCP’s activities? (For example, Will new AmeriCorps Seniors volunteers providing direct service more quickly adjust to their roles? Will the volunteer station be able to serve more clients? Will the volunteer station be able to serve clients with needs it was previously unable to meet?)

****

**I accept this assignment plan:**

****

_____________________________________		____________________

Signature:  AmeriCorps Seniors Volunteer			Date

__________________________________	   	___________________

Signature:  Volunteer Station Representative			Date

**I approve this assignment plan:**

______________________________________		____________________

Signature: AmeriCorps Seniors SCP Director			Date

Version 2020.3		Pg. 5 of 5This document is provided as a sample ONLY. Its use is optional and, if used, it should be customized as appropriate. This document is provided as a sample ONLY. Its use is optional and, if used, it should be customized as appropriate.

# image1.jpeg