| Employee's name: |
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| Department: |
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| Start date with the Company: |
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| Date request submitted: |
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| Please tick one box: |
| I wish to make a request to work flexibly in relation to my parental responsibilities (go to Section A) |
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| I wish to make a request to work flexibly in relation to my caring responsibilities (go to Section B) |
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| Section A: Please tick boxes as appropriate: |
| I declare that I have a child who is currently under 6 years of age |
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| I declare that I have a disabled child who is currently under 18 years of age |
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| I declare that my spouse/civil partner/partner has a child under 6 years of age |
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| I declare that my spouse/civil partner/partner has a disabled child under 18 years of age |
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| I declare that I am the legal guardian of a child who is currently under 6 years of age |
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| I declare that I am the legal guardian of a disabled child who is under 18 years of age |
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| I declare that my spouse/civil partner/partner is the legal guardian of a child under 6 years of age |
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| I declare that my spouse/civil partner/partner is the legal guardian of a disabled child who is under 18 |
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| I declare that I am currently fostering a child who is under 6 years of age |
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| I declare that I am currently fostering a disabled child who is under 18 years of age |
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| I declare that my spouse/civil partner/partner is currently fostering a child under 6 years of age |
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| I declare that my spouse/civil partner/partner is currently fostering a disabled child who is under 18 |
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| I declare that I live with the child and have responsibility for the child's upbringing |
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| I declare that I am making this request in order to care for the child |
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| Please state the date on which the child in respect of which you are requesting flexible working was born: |
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| Section B: Please tick boxes as appropriate (note: adoptive relationships are included): |
| I declare that I have caring responsibilities for my spouse/civil partner/partner |
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| I declare that I have caring responsibilities for someone who lives at the same address as me |
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| I declare that I have caring responsibilities for my mother/father |
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| I declare that I have caring responsibilities for my guardian |
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| I declare that I have caring responsibilities for my parent-in-law |
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| I declare that I have caring responsibilities for my step-parent |
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| I declare that I have caring responsibilities for my son/daughter/step-son/step-daughter |
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| I declare that I have caring responsibilities for my brother/sister/step-brother/step-sister/brother-in-law/sister-in-law |
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| I declare that I have caring responsibilities for my uncle/aunt |
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| I declare that I have caring responsibilities for my grandparent |
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| I declare that I have caring responsibilities for my son-in-law/daughter-in law |
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Use this document to check that an employee meets
the statutory criteria necessary for eligibility to request flexible
working.