Flexible Work Arrangement Request Form Template
[Company Name] Flexible Work Arrangement Request Form
Employee Information
- Name: ______________________________
- Position/Title: __________________________
- Department: __________________________
- Manager/Supervisor: ____________________
1. Type of Flexible Work Arrangement Requested
- Remote Work
- Flexible Hours
- Compressed Workweek
- Job Sharing
- Part-Time Work
- Other: ____________________________
2. Proposed Arrangement Details
-
Effective Date: //________
-
Duration: [e.g., 6 months, permanent]
-
Work Schedule:
- Days Working: [e.g., Monday to Thursday]
- Working Hours: [e.g., 8:00 AM – 6:00 PM]
- Location (if remote): [Home office address]
3. Rationale for Request
-
Reason(s):
-
Benefits to the Company:
- Increased productivity
- Better work-life balance
4. Impact on Job Responsibilities
-
Describe how you will meet job responsibilities under this arrangement:
-
Communication Plan with Team and Manager:
5. Manager's Review
(To be completed by Manager/Supervisor)
-
Assessment of Request:
-
Impact on Team/Operations:
-
Recommendation:
-
Approve
-
Deny
-
Comments:
-
-
Manager/Supervisor Signature: _____________________ Date: //________
6. HR Approval
-
HR Review Comments:
-
Final Decision:
-
Approved
-
Denied
-
Conditions (if any):
-
-
HR Representative Signature: _____________________ Date: //________
7. Acknowledgment
- Employee Signature: _________________________ Date: //________
By signing, I agree to the terms of the flexible work arrangement as outlined and understand that it may be modified or terminated at the company's discretion.