Request to Change a Working Pattern

Request to Change a Working Pattern

Request to Change a Working Pattern

Job title and grade
Employee number
University start date
Have you requested to change a work pattern previously – if so when?
Describe your current working pattern (days/hours/times/location worked):
Describe the working pattern you would like to work in future (days/hours/times/location worked):
If you are making the request in relation to the Equality Act 2010, for example as a reasonable adjustment for a disability, please include this below.
Is this a temporary request? If so state the time period:
I would like this working pattern to commence from (date):
What impact will the new working pattern have on the College/Directorate/ and colleagues?
I think that this proposed change in my working pattern will affect the College/Directorate and my colleagues as follows:
How could your proposed new working pattern be accommodated?
I think that the effect on the College/Directorate and my colleagues can be managed as follows:
Employee declaration
I confirm that:
  • This request is being made under the statutory right in the Employment Rights Act 1996 and the Children and Families Act 2014 to request flexible working
  • The information is accurate

Staff member signature / Date
Attachment to an e-mail will constitute signatory authorisation

Once you have completed this form you must submit it to your line manager AND copy it to your Human Resources Officer. If you have not received a receipt of your request within 14 days please contact your Human Resources Officer.

The following section is to be completed by the line managerfollowing consideration of the request. It must also be sent to both the member of staff and the Human Resources Officer.

The following adjustments to working arrangements have been agreed:
Signed by Member of Staff: ______Date: ______
Signed by Line Manager: ______Date: ______
The request has not been agreed for the following reasons:
Signed by Line Manager: ______Date: ______

If you wish to appeal against this outcome please complete the following section and forward to the Director of Human Resources, copying in the Human Resources Officer within 14 days of receipt of this written communication.

I wish to appeal against the decision to decline my variation of working arrangements for the following reasons:

The member of staff will be informed (by the individual hearing the appeal) of the outcome of the appeal meeting in writing using the section below. The following people will be notified of the outcome:

  • Member of staff
  • Line Manager
  • Human Resources Officer
  • Director of Human Resources

Appeal outcome:
Signed: ______Date: ______

The appeal decision is final, but does not deny the employee the statutory right to take their complaint to an Employment Tribunal and to the Advisory, Conciliation and Arbitration Service (ACAS).