Request for Flexible Working

Application Form

Before completing this form, please read the UECS Flexible Working Policy.

You should download this form and save it on your computer before completing it.

Employee Details

Surname:	Click to enter text	Forename/s:	Click to enter text
Department:	Click to Select	Employment Start Date:	Click to enter date
Home telephone (if away from workplace):	Click to enter text
Home email (if away from workplace):	Click to enter text
Have you made a previous request?	Click to select
If yes, date of previous request:	Click to enter date

Reason(s) for Request (Optional)

Caring Responsibilities:	☐
Returning from Family Leave:	☐
Health or Disability Reasons:	☐
Prepare for Retirement:	☐
Pursue Personal Interests:	☐
Other (please detail):	Click to enter text

Detail if Permanent or Temporary Change

If Permanent:	Select start date
If Temporary:	Select start date	Select end date

Details of Flexible Working Request

Reduction in Hours:	☐
Compressed Hours:	☐
Annualised Hours:	☐
Term Time Only Working:	☐
Job Share:	☐
Other (please detail):	Click to enter text

Please provide further detail of your request in the box below, including the working hours and pattern you are seeking. The box will expand as you type.

Employee Signature

Print Name:	Click to enter text	Date Signed:	Select Date …
Signed:
Sign the form by either typing your name or uploading a JPEG image of your signature. Save the form and send it by email to your manager.

Manager Decision

Request Approved or Rejected:	Click to Select
If approved, confirm start date:	Click to enter date
Approval Supporting Comments:
If rejected, confirm reasons for rejection below:
Burden of additional costs:	☐
Inability to reorganise work among existing staff:	☐
Detrimental impact on quality:	☐
Insufficient work for the periods the employee has requested to work:	☐
Detrimental effect on the ability to meet customer demand:	☐
Inability to recruit additional staff:	☐
Detrimental impact on performance:	☐
Planned structural change:	☐
If the original request has been rejected and an alternative arrangement has been proposed and agreed, please provide details below:

Manager Signature

Print Name:	Click to enter text	Date Signed:	Select Date …
Signed:
Sign the form by either typing your name or uploading a JPEG image of your signature. Save the form and send it by email to People & Culture.
If you have approved the flexible working request, you will also need to complete the Contract of Employment Change form and send it by email to People & Culture.