Severe Weather Accommodation Request Form

This form is for use during the Severe Weather Plan only. It is intended for Severe Weather Critical employees only.

Sleeping accommodations will not be provided for employees who live within the Winston-Salem city limits and may also be transported by Medical Center Security to work. Instead, those employees will be transported home after working their shift.

Sleeping accommodations will be provided as available for employees who are transported by Medical Center Security, live outside of the Winston-Salem city limits and are working extended hours.

All fields are required.

 

First name: Last name:
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.
  

 

  

 

 

 

 

Quick Reference

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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.