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Severe Weather Accommodation Request Form

This form is for use during the Severe Weather Plan only. Sleeping accommodations will be provided as available for employees who live outside the Winston-Salem city limits and are working extended hours.  

All fields are required.

 

First name: Last name:
Zip Code:  Gender:
Title: Unit:  
Do you provide clinical care?
    
Contact phone number:
Please include the area code.
Date/time shift begins:
Date/time shift ends:
Accommodations needed:
    
Preferred date and time for room:
Manager or Designee:
Manager or Designee's phone number:
Manager or Designee's e-mail address:

Please click submit ONLY once.
  

 

  

 

 

 

 

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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.

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