Flexible Working Application Form - HR 111
This form is to be used by employees to apply for Flexible Working under
the terms of the HSE Flexible Working Scheme
Information will be input on the HR /Payroll system for the purposes of Personnel and Payroll Administration
HR111_V2 Apr 2010 Page 1 of 3 Revised 01/04/2010
Section 1. To be completed by the employee
I wish to apply for Flexible Working in accordance with the terms and conditions applicable to the Flexible Working
Scheme.
Surname: First Name:
Personnel No: PPS Number
Proposed Start
Date
Review Date*
Grade:
Number of Hours I wish to work per week/ fortnightly (in Decimals) Hrs
Please state your preferred attendance arrangements
Day of the Week Start Time End time Break time Start Break time end Hours per day
If my application is accepted, I agree to notify my Line Manager and Human Resources of any changes that impact
on the terms and conditions applicable to the granting of flexible working.
Signature
Date
Name: Mobile No:
Contact Phone No:
Section 2. To be Completed by the Line Manager
I have discussed the application with the employee and recommend that the application is
Approved Refused Please () Tick one
If Application is refused outline reasons for refusal
* Line Manager should review the arrangement on an annual basis in terms of addressing real service demands.
If Faxing please ensure that the Employee’s Name and Personnel Number are included on each page of the form
Name: Personnel No:
HR 111_V2 Apr 2010 Revised 01/04/2010
Page 2
Circulation List
of 3
Agreed Contract Hours per week/Fortnight (use decimals if less than whole time hours) Hrs
Agreed attendance arrangements
Day of the Week Start Time End time Break time Start Break time end Hours per day
Working Week 5 / 5 5 / 7
Work Schedule rule details (SAP Phase II Sites Only)
Work Schedule Rule 1. Start week of Rotational Roster 2.
Agreed Start Date
Is the employee to be assigned to a different position Yes No
If Yes provide New position Number
Position Name
Previous occupant (if Known)
Section 3. Line Managers Declaration
I declare that the above information is accurate and correct on the date indicated below.
Signature: Date:
Name: Grade:
Contact Phone No: Mobile No:
E-mail Address:
Section 4. Area Employment Monitoring Group
Approval No Date
Section 5. Delegated Officer Approval
Name (Print) Signature
Tel No Date
Decision No
If Faxing please ensure that the Employee’s Name and Personnel Number are included on each page of the form
Name: Personnel No:
HR 111_V2 Apr 2010 Revised 01/04/2010
Page 3
of 3
Section 6. To be completed by Human Resources, Personnel Administration
System Updated by: Date
Section 7. Payroll Section
Name (Print) Signature
Grade Date
Section 8. Payroll Interface (SAP Phase 1 specific)
Location Code
Wage Type Payroll Area
Employment Signal Effective date
Name:
Section 9. Circulation List
1 2
3 4
5 6
7 8
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