Care Extender Forms

Here's important information regarding Hours Verification, Inactivation/Completion Request, and Leave of Absences.

Hours Verification(Link downloads document)

To request documentation of your hours or a letter of hours verification, complete the hours verification request form and send it to the Administrative Coordinator at CEAdmin@mednet.ucla.edu. Please note that this is not the same as a letter of reference or recommendation.

Inactivation/Completion Request(Link is external) (Link opens in new window)

To complete the inactivation/completion request, use the "Exit Request" link in your Samaritan volunteer profile. Hold onto your badge until further instructions. If eligible, you will receive a completion certificate, letter of reference, and documentation of your hours by mail. The completion certificate can be requested within one year of program completion. For questions on completion eligibility, email the Administrative Coordinator at CEAdmin@mednet.ucla.edu. Submit your badge to the Care Extender Office (excluding badge clip) in person or by mail to the following address: 1328 16th St. 2nd Floor, Santa Monica, CA 90404.

Leave of Absence(Link is external) (Link opens in new window)

Care Extenders are allowed one 2-week vacation and one 13-week leave of absence each year in the program. To request a leave of absence, submit your request two weeks prior to your requested leave. Care Extenders in their first rotation are only allowed to take the 2-week vacation. During the leave of absence period, Care Extenders are prohibited from volunteering in their department. Log in to the Samaritan volunteer portal and select "Request Leave" to submit your request. If you have any questions, please email the LOA Coordinator at CynthiaDang@mednet.ucla.edu.