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Eisner Prize Winner

Program of Distinction

UJA-New York

Response Team Feedback Form 2019

  Thank you for volunteering. Please fill out the form below including any pertinent information about the person you assisted today. Your comments alert DOROT to the current needs of this person.

  Your information:









Question - Required - Date that you assisted this senior:

* Length of time volunteer spent on phone with senior (aide, etc.) to arrange opportunity:
(Select one of the available choices or enter a different value.)

* Length of visit/volunteer opportunity (Includes time spent traveling with senior if applicable). Approximately:
(Select one of the available choices or enter a different value.)

Question - Not Required - What type of assistance did you provide?




Question - Not Required - Response Team visits are a one-time commitment, unless otherwise specified. However, if you plan to visit the senior again, please check one of the following:

  Please remember to inform DOROT of any return visits you make to a senior, and to fill out a feedback form after each visit.
Question - Required - Overall, how would you rate your volunteer experience?



  After you click ‘Submit’, you will receive an email confirming submission of your form. If you do not receive this email, please email Miranda Perez at to follow up.
   Please leave this field empty


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