COVID-19 - Community Medical Services Leave Request Form

Are you being recalled to Active Duty in the Military to support communities with COVID-19 needs?*

(If yes, DO NOT fill out this form and apply for standard Military Leave - https://aboutyou.verizon.com/HRGuidelines/LifeAndTimeOff/TimeOffAndLeaveInformation/MilitaryLeave)

Yes

Employee ID (Not Enterprise ID)*

This can be located on VZWeb by clicking the dropdown on the upper right and selecting My Work Profile. Employee ID can be found under Employee Info. (6-7 digits)

Full Name (Last, First)*

Personal Email Address*

Personal email address is requested so that we can reach you during the COVID-19 emergency and to communicate regarding this request. If you do not provide your personal email, we will contact you at your VZ email.

Personal Phone*

Personal phone is requested so that we can reach you during the COVID-19 emergency and to communicate regarding this request.

Is this a new request or are you requesting an extension to a prior approval?*

New

Extension

What is the requested start date of your leave?*

What is the requested end date of your leave?*

What is the date that you will begin providing COVID-10 Community Medical Support Services?

How many hours per week will you be providing community medical services?*

Select

Do you need continuous or intermittent leave?*

Continuous

Intermittent

If Intermittent, indicate the days of the week that you are requesting leave for?

Select

Are you currently working from home?*

Yes

Do you hold a medical certification?*

Yes

Select the nature of your medical certification.*

Select

If other, describe your medical certification

If none, please explain why you are applying to provide Community Medical Support Services.

What is the name of the facility where you will be providing Services?*

What is the address of the facility?*

Are you receiving pay for your COVID-19 Community Medical Support Services?*

Yes

If you are receiving pay while providing community support medical services, please select the frequency of pay.*

Select

If you are receiving pay while providing community support medical services, please state the amount for selected frequency above.*

Please type 'N/A' if not receiving pay for your service.

File Attachments*

Please provide documents to verify the following: 1. Your medical certification 2. Call for community medical support (advertisement, letter, etc.) 3. Confirmation of acceptance for your medical support services 4. Name and location of the facility where you will be providing medical support 5. Description of the community medical support services you will be providing while on leave 6. Confirmation of pay/non-pay

Drag and drop files here or

By submitting this request, you are representing that:

1. You have the above described medical certification 2. The information you have provided in the form and the attachments is true and accurate, including the description of medical services, facility where you will be working, and pay (if any) 3. If your assignments ends or diminishes prior to end of approved period, you will notify Verizon to start appropriate workplace re-entry process

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