Flexible Working Request Form

Please refer to the Flexible Working Policy and Procedure, prior to completing this form. Submission of this form is a formal request to change your working pattern and therefore your terms and conditions of employment.

Personal Details

Title:

Preferred First Name:

Forename(s) (as shown on passport):

Surname (as shown on passport):

Home Address:

Personnel No.:

Academic/Service Unit:

Email Address:

Extension No.:

Describe your current working pattern

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Days worked
Hours worked

Any other relevant details: e.g. term time, work from home:

Describe the working pattern you wish to adopt

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday
Days worked
Hours worked

Any other relevant details: e.g. term time, work from home:

From what date do you request the proposed work pattern be effective? Click here to enter a date.

Please provide details below, as far as you are able, the effect, if any, you think the proposed work pattern would have on the School/Service and University, and how you think these could be dealt with:

……………………………………………………………………………………………………………

Declaration

Have you made a previous application to change your work pattern in the past 12months?

Yes

No

I confirm that the information provided within this form is true and correct and that I meet the eligibility criteria for making such a request.

I confirm that I have discussed the request with my Line Manager.

Signature: Click here to enter text. Date: Click here to enter a date.

Confirmation by Manager

Date Received: Click here to enter text. Date of meeting:* Click here to enter text.

*Meeting to discuss the request must take place within four weeks of receipt of this form

Approved/Not Approved: Click here to enter text.

If not approved please provide a reason Click here to enter text.

Signature: Name: Click here to enter text. Date: Click here to enter a date.

Section to be completed by HR Manager/Adviser

Date received: Click here to enter text. Signature: Click here to enter text.

Print name: Click here to enter text. Position: Click here to enter text.

HR Office use only

Date received and logged: Click here to enter text.

Date correspondence sent: Click here to enter text.