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Dear ________,

RE: STATUTORY REQUEST FOR FLEXIBLE WORKING

1. I am writing to make a request for a change to my terms and conditions of employment in relation to flexible working. This is a statutory request made under section 80F of the Employment Rights Act 1996, as amended by the Employment Relations (Flexible Working) Act 2023, and pursuant to the Flexible Working Regulations 2014. Where applicable, I also rely upon my contractual right to request flexible working under the NHS Terms and Conditions of Service.

2. I have been continuously employed by ________ since ________ in the role of ________. My employee or staff identification number is ________.

3. I confirm that, to the best of my knowledge, I am eligible to make this statutory request and that I have not made another statutory flexible working request in the preceding twelve months.

4. My current working arrangements are as follows:

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5. I request that my terms and conditions of employment be varied so as to change my working arrangements to the following:

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6. I would like this change to take effect on ________, and I understand that, if agreed, this would amount to a permanent variation of my contract of employment unless otherwise agreed in writing.

7. The reasons for my request, and an explanation of what effect, if any, I think the change would have on my employer and how, in my opinion, any such effect might be dealt with, are set out below.

8. My request relates, in part, to health and safety concerns. I am particularly concerned about the following:

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9. I consider myself to be at increased risk in view of the following condition: ________.

10. I also wish to advise you that I have a disability within the meaning of section 6 of the Equality Act 2010, namely: ________. As a result of that disability, I currently experience the following substantial disadvantages in the course of my work:

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Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor in reprehenderit voluptate velit esse cillum dolore eu fugiat nulla pariatur lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt.

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12. I believe the requested changes would have the following beneficial effects for ________:

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13. I appreciate that the requested changes may give rise to the following issues for ________:

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14. In my view, these issues could reasonably be addressed in the following way:

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15. I confirm that I have not previously made a statutory flexible working request in the last twelve months, save as follows (if applicable): ________.

Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor in reprehenderit voluptate velit esse cillum dolore eu fugiat nulla pariatur lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris.

17. I would be grateful for written confirmation of receipt of this request. Should my request be refused, I understand that it may only be refused on one or more of the statutory grounds set out in section 80G(1)(b) of the Employment Rights Act 1996, and I would expect to be given the reasons for any such refusal and to be offered a right of appeal.

Yours sincerely,



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