Flexible Working Application form

1. Flexible Working Application Form for Staff on Simply Safe Care Group Terms and Conditions

Please make sure you read WPE02 - Flexible Working Policy and Procedure. this form is to be used in conjunction with this policy. The right to request flexible working was introduced in 2003 for parents of young and disabled children and the scope of the law was extended to carers of certain adults in 2007. Any request that is made and accepted under the statutory right will result in a permanent change to the employee’s contractual terms and conditions. The employee has no right to revert back to their previous working pattern.You should note that under the right it may take up to 14 weeks to consider a request before it can be implemented and possibly longer where difficulties arise. You should therefore ensure you submit your application to the appropriate person well in advance of the date you wish the request to take effect.

1. Employee Personal Information


2. I would like to apply to work a flexible working pattern that is different to my current working pattern. I confirm that:
Please select the relevant statements below. You must be able to tick the first two boxes to be eligible to request flexible working.

I have continuous service as an employee of Simply Safe Care Group for more than 26 weeks
I have not made a request to work flexibly under the Flexible Working Policy in the past 12 months or I have made a request within the last 12 months but since then have been subject to a substantial change in my home life.
I have responsibility for the upbringing of a child under 17 or a disabled child under 18
I am the mother, father, adopter, guardian, special guardian or foster parent of the child
I am Married to, or the partner or civil partner of, the child’s mother, father, adopter, guardian, special guardian or foster parent.
I am making this request to help me care for the child
I am, or expect to be, caring for an adult
I am the spouse partner, civil partner or relative of the adult in need of care;
I am not the spouse, partner, civil partner or relative of the adult in need of care, but live at the same address
I am making this request to help me care for the adult in need of care.
The reasons stated above do not apply to me and I am making this request for other reasons. Please give details:

3. Describe your current working pattern (days/hours/times worked):


4. Describe the working pattern you would like to work in future (proposed days/hours/times of work):


5. I would like this working pattern to commence from:


6. Are you willing to undertake a trial period of up to 3 months to assess the practicability of arrangements?


7. Are you requesting that this working pattern ist a permanent change? Give reasons for this


8. If not permanent, give the proposed end date of this working pattern.


9. Impact of the new working pattern. (it is recommended that you consult your line manager and work colleagues before completing this section).I think the proposed change in my working pattern will affect my current duties, my colleagues, as follows:


if your application is acceptable you will need to sign this at a later date.