Care Extender Forms

Forms for UCLA Care Extender Program

The Leave of Absence form should be submitted to the Leave of Absence Coordinator, Benjamin Chiang, at BChiang@mednet.ucla.edu. The Change of Information form, Extension Request form, Reorientation Quiz, and TB Questionnaire should be submitted to the Administrative/Extension Coordinator, Kevin Lee, at KYLee@mednet.ucla.edu. The Inactivation/Completion Request form should be mailed along with your volunteer ID badge to the Care Extender Office.