Flexible Working Arrangement Request Form Template

Flexible Working Arrangement Request Form

Employee Details

Name: [Full Name]

Job Title: [Job Title]

Department / Team: [Department Name]

Employment Type: [Full Time / Part Time / Casual]

Date of Commencement: [DD/MM/YYYY]

Request Details

I am requesting a flexible working arrangement for the following reason:

[ ] I am a parent or have responsibility for the care of a child of school age or younger [ ] I am a carer (within the meaning of the Fair Work Act 2009) [ ] I have a disability [ ] I am aged 55 or older [ ] I am experiencing domestic violence [ ] I am providing care or support to a member of my household or immediate family who is experiencing domestic violence [ ] Other (please specify): [Details]

Changes Requested

Please describe the changes you are requesting to your working arrangements:

[ ] Change to hours of work (e.g., start and finish times) [ ] Change to patterns of work (e.g., days of the week worked) [ ] Change to location of work (e.g., working from home)

Specific Details

I wish to change my working arrangements from [Current Arrangement] to [Proposed Arrangement].

I would like this arrangement to start on: [DD/MM/YYYY]

This arrangement will be: [ ] Permanent [ ] For a specified period: [Duration/End Date]

Reasoning and Impact

Please explain how this change will help you manage your circumstances:

[Type explanation here]

Please explain how you propose to perform your duties while working under this arrangement:

[Type explanation here]

Please explain any potential impact this arrangement might have on the workplace or your team and how you suggest managing this:

[Type explanation here]

Supporting Documentation

Have you attached any supporting documentation? (e.g., medical certificate, statutory declaration) [ ] Yes [ ] No

Employee Declaration

I declare that the information provided in this form is true and correct.

Employee Signature: __________________________

Date: __________________________

Employer Section Only

Decision on Request

[ ] Approved [ ] Approved with conditions [ ] Refused

If approved with conditions, please specify conditions:

[Type conditions here]

If refused, please specify the reasonable business grounds for refusal:

[ ] The grounds are too costly [ ] There is no capacity to change the working arrangements of other employees [ ] It is impractical to change the working arrangements of the employee [ ] It would likely result in a significant loss in efficiency or productivity [ ] It would have a significant negative impact on customer service

Details of grounds:

[Type details here]

Manager Name: __________________________

Manager Signature: __________________________

Date: __________________________