Flexible Working Arrangement Request Form Example
Example document for Flexible Working Arrangement Request Form. Use this as a reference when creating your own.
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Document: Flexible Working Arrangement Request Form
Example Document
Last updated 7/30/2026
Flexible Working Arrangement Request Form
Employee Details
Name: Sarah Jenkins
Job Title: Senior Electrician
Department / Team: Projects Team
Employment Type: Full Time
Date of Commencement: 15/02/2018
Request Details
I am requesting a flexible working arrangement for the following reason:
[X] I am a parent or have responsibility for the care of a child of school age or younger
Changes Requested
Please describe the changes you are requesting to your working arrangements:
[X] Change to hours of work (e.g., start and finish times)
Specific Details
I wish to change my working arrangements from 7:00am to 3:30pm Monday to Friday to 6:30am to 2:30pm Monday to Friday.
I would like this arrangement to start on: 01/07/2023
This arrangement will be: [X] Permanent
Reasoning and Impact
Please explain how this change will help you manage your circumstances:
My daughter is starting school next term and I need to pick her up from school at 3:00pm. Finishing at 2:30pm allows me travel time to reach the school on time.
Please explain how you propose to perform your duties while working under this arrangement:
I will start 30 minutes earlier. This ensures I complete a full 8 hour shift. I will organise my tools and materials the afternoon prior to ensure I am ready to start immediately at 6:30am.
Please explain any potential impact this arrangement might have on the workplace or your team and how you suggest managing this:
Leaving at 2:30pm means I may miss the daily 3:00pm site meeting. I will ensure my daily progress reports are submitted by 2:00pm and I will call my supervisor at 3:15pm to catch up on any missed information.
Supporting Documentation
Have you attached any supporting documentation? (e.g., medical certificate, statutory declaration) [ ] Yes [X] No
Employee Declaration
I declare that the information provided in this form is true and correct.
Employee Signature: S Jenkins
Date: 10/06/2023
Employer Section Only
Decision on Request
[X] Approved [ ] Approved with conditions [ ] Refused
If approved with conditions, please specify conditions:
N/A
Manager Name: David Smith
Manager Signature: D Smith
Date: 20/06/2023
Notes
This example shows a tradie requesting a simple change to start and finish times to accommodate school pickup. The employee clearly explains the reason, the proposed solution, and addresses the potential conflict with the 3pm meeting.
About this Example
Part of the Flexible Working Arrangement Request Form document collection
Document Type
Flexible Working Arrangement Request Form
A standard form used by eligible employees to formally request changes to their working hours, patterns, or locations under Australian employment law.