Flexible Working Decision Appeal Form

1.	Please complete this form if your manager has declined your request to work flexibly and you wish to  appeal against their decision.  
2.	You must complete the form within 14 days of receipt of the decision from your manager declining your flexible working application. 
3.	Please send a copy of the completed form to the manager of your line manager or the next level of management within the Service.
4.	On receipt of the form, you will be invited to an appeal hearing which will normally be conducted by the line manager of your manager who rejected your request to work flexibly.
5.	Further information on the appeal process can be found in Flexible Working – Guidance  for Employees.

Name:	     	
Job title:	     	
Department:	     	
Name of your manager who rejected your flexible working application:	     	
Date of flexible working meeting:	     	
Date you received the decision:	     	
Name of your work colleague,   union representative or support worker who will accompany you to the appeal: 	     	
Please state the grounds of your appeal (e.g. procedural, new information not raised at the Flexible Working Meeting or a challenge to the facts in the reasons your manager gave when rejecting your request):	     	
Signature: 	Date:      	
Receipt of this form must be acknowledged