Flexible Working Request Refusal Form
Use this form to record the refusal of an employee flexible working request, including the request details, reason for refusal, decision maker information, and any follow-up actions.
Employee and Request Details
Employee full name
*
First Name
Middle Name
Last Name
Job title
*
Department
Work location
Manager or supervisor name
First Name
Middle Name
Last Name
Date flexible working request submitted
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of flexible working requested
*
Remote working
Hybrid working
Adjusted hours
Compressed hours
Part-time hours
Staggered start/finish times
Job share
Other
Brief summary of the request
Refusal Decision Details
Date of Refusal
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Refusal Decision Status
*
Refused
Partially Refused
Reason(s) for Refusal
*
Insufficient staffing coverage
Operational demands during requested period
Impact on customer service or service levels
Inability to reorganize work among team members
Budgetary or resource constraints
Health and safety concerns
Training or supervision requirements
Other
Detailed Refusal Explanation
*
Was an Alternative Arrangement Considered?
*
Yes
No
Details of Alternative Arrangement Offered
Decision Maker and Communication
Decision maker name
*
First Name
Last Name
Role / title
*
Department / team
*
Date refusal was communicated
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred communication method
*
Email
Meeting
Letter
Phone call
Video call
Other
Person who communicated the decision
*
First Name
Last Name
Notes on discussion or employee response
Follow-up and Review
Was a review or appeal requested?
Yes
No
Date of review or appeal request
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Review outcome
Please Select
Upheld
Partially upheld
Overturned
Pending
Not applicable
Next steps or follow-up actions
Target review date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Internal notes
Submit Refusal Record
Should be Empty: