Flexible Working Arrangements Request Form - Adm.monash.edu.au

Flexible WorkingArrangements RequestForm for Parents & CarersInstructions for completing this form1. Before completing this request form applicants should read:a. the flexible working arrangement provisions of the relevant EnterpriseAgreement;b. the Workforce Management Procedure - Flexible Working Arrangementsfor Parents and Carers; andc. the Workforce Management Guideline – Flexible Working Arrangementsfor Parents and Carers.2. To obtain a copy of the procedures and guideline or to receive assistance incompleting this form please contact Access HR 9902 0400Policy and Procedure ReferencesFlexible Working Arrangement provisions are included in the applicable WorkforceManagement Procedure - Flexible Working Arrangements for Parents and Carers and theWorkforce Management Guideline – Flexible Working Arrangements for Parents andCarers.Who should complete this form?This form should be completed by a staff member who is requesting flexible workingarrangements on the basis of parental or carer responsibilities. Where the requestfor flexible working arrangements requires the consideration of a working from homearrangement, compliance with the Workforce Management Procedure – Work Life(Home-based Work) will also be required.Note: Staff members seeking flexible working arrangements following a period ofparental leave should not use this form and should complete the FlexibleReturn/Extension of Parental Leave Application.When should this form be completed?If you are applying, this application form should be submitted to your supervisor at least 6weeks prior to the date that you propose the flexible working arrangements start. It issuggested that you submit the application no earlier than 3-6 months prior to this date asthe University will be in a better position closer to the relevant start-date to assesswhether the request can reasonably be accommodated taking into account both yourcircumstances and reason for the request and the operational requirements of your role,unit and potential impact upon other staff.It is also recommended that you have a preliminary discussion with your supervisor todiscuss the proposed flexible working arrangements and availability of any alternativeoptions, prior to completing this form.Where to send this form?Scan or fax your completed form to your supervisor.

Your supervisor will consider your request and inform your HR Business Partner andhead of unit. Your head of unit is responsible for deciding if your requested flexibleworking arrangement can be accommodated.If your request is approved, a copy of the approved form will be: provided to you; and retained by your supervisor/organisational unit.Further information can be found in the Workforce Management Procedure – FlexibleWorking Arrangements for Parents and Carers and the Workforce Management Guideline– Flexible Working Arrangements for Parents and Carers.SECTION 1 – STAFF MEMBER’S DETAILSTitle Family Name Given Name(s)Email AddressTelephone No __ __ - __ __ __ __ __ ____ __ AH/BHSECTION 2 – EMPLOYMENT DETAILSMobileOtherOrganisational UnitPersonnelNumberPosition TitleCampusAcademic Research Technical Trades & Services AdministrationSECTION 3 – FLEXIBLE WORKING ARRANGEMENTPart TimeJob-shareFlexible work hoursHome-based workVoluntarily reduced working yearOther_______________________________________________________________________________Date flexible working arrangement is proposed to startDate flexible working arrangement is proposed to end___ / ___ / _________ / ___ / ______

SECTION 4 – SCHEDULE PROPOSED (Provide details of the schedule proposed where this isrelevant to the request)MondayTuesdayWednesdayThursdayFridayTotal fortnight/weekly hoursHours/times Location SpecialArrangementsIf you are an academic staff member and your proposed schedule involves a reduction in your workfraction, what is your anticipated proportionate allocation of research, education and serviceactivities during the period of your reduced work fraction?Research_____%Education_____%Service_______%SECTION 5 – ADDITIONAL INFORMATION (To be completed by the requesting staff member)If applicable, what is the nature of your carer and/or parental responsibilities and to whom do theyrelate?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What are your duties and your work role and what is the likely impact upon your duties and yourwork role if the flexible working arrangement is approved?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

SECTION 5 – ADDITIONAL INFORMATION (To be completed by the requesting staff member)continued:What is the likely impact upon the work unit and other staff if the flexible working arrangement isapproved? Who will be affected and how?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Do you have any suggestions for how the impact of the requested flexible working arrangement onyour work role and/or the work role of others can be addressed?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What advantages/disadvantages (including any additional cost) does this requested flexibleworking arrangement involve?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………What other arrangements have you considered? Would you be prepared to move to another role ifnecessary to accommodate the request for the flexible working arrangement and, if so, what roledo you consider you could be considered for taking into account your skills and experience?………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………If you are requesting a flexible working arrangement to accommodate your parental responsibilities:• is your child/children of pre-school age? □ Yes □ No• is your child/children under 18 years with a disability? □ Yes □ NoDo you have any other comments that you wish to have taken into consideration? (Detail on aseparate sheet if needed.)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………SECTION 6 – ACKNOWLEDGMENT OF STAFF MEMBER1. I declare that the information I have provided is accurate.2. Notwithstanding any representation to the contrary, I acknowledge that the Universitymay refuse to approve my request for a flexible working arrangement on reasonablegrounds.3. I acknowledge that this request is conditional upon and subject to approval of anauthorised officer of my faculty/division and approval and confirmation by an officer of

Monash HR acting for the Executive Director, Monash HR, on behalf of the UniversityCouncil.4. If applicable, I acknowledge that the request for a flexible work fraction is for anagreed period and that the University is under no obligation to continue thisarrangement beyond the agreed period. Upon the expiry of this agreed period Iacknowledge that I will return to my substantive work fraction.5. I acknowledge that if the University has agreed to approve my flexible workingarrangement by adopting the proposed schedule contained in section 4 of thisapplication for an agreed period or time, that at the expiration of the agreed period theUniversity is under no obligation to continue this arrangement. Upon the expiry of thisagreed period I acknowledge that I will return to my existing work schedule in mysubstantive position unless otherwise agreed.Signature of ApplicantSignature Please print name Date__ / __ / ______Contact Extension No.Note: If the request is approved the new arrangements will be in accordance withconditions of employment as provided with your existing contract of employment.Employment guidelines and policies may be found in the Workplace Policies andprocedures at http://adm.monash.edu/workplace-policy/ as varied from time to time.SECTION 7- AUTHORISATIONAuthorisation 1 - Head of UnitSignaturePlease print nameAuthorisation 2 – Required if approving unpaid leaveof greater than 6 monthsDeputy Vice-Chancellor (Education)for academic staff/ Vice-President Administration for non-academic staffSignaturePlease print nameContact Ext No. __ __ __ __ __ Date __ __ / __ __/ __ __ Contact Ext No. __ __ __ __ __ Date __ __ / __ __/ __ __FORM TO BE RETAINED ON STAFF MEMBER’S PERSONNEL FILE BY HR OPERATIONSFOR MONASH HR USE ONLYFor assistance please contact Access HR on 9902 0400Processed by Date / / Checked by Pay PeriodMonash HR privacy collection statement is located athttp://privacy.monash.edu/guidelines/collection-personal-information.html#hr