The right to request flexible working arrangements
Form A: Request for flexible working arrangements
You can download this form as a RTF[3 pages, 25 KB] or PDF[3 pages, 65KB]
Making a request for flexible working arrangements
Are you eligible for the right to request flexible working arrangements?
If you care for someone and have worked for your employer for 6 months or more, chances are that you will be eligible for the right to request flexible working arrangements.
To make certain you are eligible it’s best to check out the Department of Labour’s guidelines.
How to apply
Once you’ve confirmed that you’re eligible, requesting flexible working arrangements is straightforward. You can use this form to make your request.
The more information you give, the easier it will be for your employer to make a decision about your request.
Make sure that you complete all the sections of the request form, including the sections that tell your employer:
- How the flexible working arrangement will enable you to provide better care for the person concerned.
- What effect your new working arrangement will have on your employer and colleagues.
- How the effects on your employer and colleagues could be dealt with.
Apply well in advance
Your employer has 3 months to deal with your request, but it could take longer if difficulties arise. So make sure you:
- apply well in advance
- submit your request as soon as it’s complete
- keep a copy of your request and note when you submitted it.
Request for Flexible Working Arrangements
(Type/write your name and address)
To (Use either your employer’s first name or surname)
(Include full name and address)
I would like to request a variation to my current working arrangements under Part 6AA of the Employment Relations Act 2000. I confirm that I meet the eligibility criteria as follows:
- I have the care of a person, and
- I have been employed by this business for the last 6 months, and
- I have not made a request to work flexibly under Part 6AA during the past 12 months.
Date of any previous request to work flexibly under this right: (If applicable)
If you are not sure whether you meet the eligibility criteria, information can be found in the eligibility section of the guidelines. If you do not qualify to make a request to work flexibly under Part 6AA, this does not mean that your request will not be considered. Many employers currently offer flexible working arrangements to their staff as best practice. You can expect any request to amend your terms and conditions of employment to be considered by your employer.
See our Flexible work area for further advice.
My current working arrangement is:
Place of work: (Give full street address)
Days and hours of work:
Example: Monday to Friday 8.00am to 5.00pm
The working arrangement I would like to have in the future is:
Place of work: (Give full street address)
Days and hours of work:
Example: Monday and Tuesday 8.00am to 1.00pm,
Wednesday to Friday 8.00am to 5.00pm
I would like the new working arrangement to be permanent and commence from:
Example: Monday 1 September 2008
OR
I would like the new working arrangement to be temporary commencing from:
Example: Monday 1 September
and ending on:
Example: Friday 31 October
The new working arrangement will enable me to provide better care for the person concerned because:
Example: I will be able to take care of my mother on Monday and Tuesday afternoons to give her regular caregiver a break.
The new working arrangement will affect my employer and colleagues in the following way:
Example: I will not be able to work with James on Monday afternoon as I do now.
I think the effect on my employer and colleagues can be dealt with by:
Example: James and I could work together on either Thursday or Friday afternoon.
Personal details
Name:
Staff or payroll number:
Manager:
Signed: Date:
Note to your employer
This is a request for flexible working arrangements made under Part 6AA of the Employment Relations Act 2000. You must deal with this request within 3 months of the date you received it.
You can confirm receipt of this request using the attached confirmation slip.
Forms and guidelines for responding to this request.
Cut this slip off and return to your employee to confirm your receipt of their request.
Employer’s confirmation of receipt (to be completed and returned to employee)
To:
I confirm that I received your request to change your working arrangement on:
Signed: Date:
You will receive a response to this request within 3 months.
NOW ATTACH THIS COVERING NOTE TO THE REQUEST FORM AND PASS TO YOUR EMPLOYER
