CHRIS/74 Application for Temporary Leave (up to 5 years) from a niversity !

ffice to "or# $le%i&ly

Please discuss your plans with your manager or Head of Institution before completing this form, which is to be completed to apply to work flexibly, eg part-time, for a period of up to 5 years. Information on this type of leave is set out in the $le%i&le "or#in' (olicy on the Human esources !ivision webpages.

(ART ) * A((LICATI!+ $!R L,A-,

To be completed by the employee

Section A * (ersonal an. ,mployment /etails Please answer all *. +urname "uestions. #our personal reference number can be ,. -orenames found on your payslip. .. Personal eference /umber $uestions % and &' it is very important that we 0. Position Held know what days of the week you are working in 5. -aculty 1 order that we can !epartment calculate your leave entitlement correctly. In %. 2urrent working pattern "uestion &, tell us the 3very weekday 4onday--riday start date of this pattern +pecified below (even if in the past). If your pattern changes 4on 5ue 6ed before you go on leave, you must tell us. &. +tart date of this pattern

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Section 2 * /etails of leave to 3or# fle%i&ly If you are unsure whether this is the right type of 45 "6at fle%i&le arran'ement is re7ueste.8 leave to apply for then contact your eduction in hours !epartmental +ame hours and days but different times 7dministrator. +ame hours but different days 8ob-share 5he start and end dates 7nnualised hours of flexible leave should be specified. 7 maximum of 95 "6at is t6e reason for t6e re7uest8 5 years can be applied for. 2arer responsibilities 2hildcare Health Preparation for retirement +tudy 9oluntary work :ther (please specify)

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;. +tart date of flexible working *<. 3nd date of flexible working 2H I+1&0, 9ersion *, ,&1<.1,<*.

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**. 6as the re"uest' 7greed without amendments 7greed with amendments

Section C * A..itional information Please indicate in the space on the right any information in support of your re"uest for leave of absence. Please note that if you hold a 2ollege appointment in addition to your =niversity appointment, the following conditions apply' #ou should advise the 2ollege of your intention to take leave before completing this form and any accommodation and research support needs during this period.

*,. Please provide additional information about the reason for your re"uest to work flexibly>

*.. 6hat arrangements would need to be put in place to cover the hours you would no longer be working under your new flexible working arrangement>

Section / * Hours an. 3or#in' pattern Indicate in "uestion *0 *0. 6ill you be working flexibly on a part-time basis> if the appointment is #es (: complete t6is section) /o (: 'o to ne%t Section) part-time. If you have answered ?#es@, you must complete *5. Hours per week "uestions *5 and *%. .& hours is treated as full-time.

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Part-time hours should be rounded up to the nearest half day, i.e *<A B half a dayC ,<A B full day.

*%. 6orking pattern 3very weekday 4onday--riday 9ariable /ot known +pecified below 4on 5ue 6ed

/umber of days per week if known

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Section , * /eclaration I apply for leave as set out above. Si'ne. (applicant) !ate

1ou s6oul. pass t6is form to your Hea. of /epartment for completion of Section $5

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(ART ; * I+STIT TI!+AL A TH!RISATI!+

This part must be completed by the Chairman/Secretary of the Faculty Board or equivalent . Please ensure that the following steps have been followed prior to the submission of this form to the uman !esources "ivision.

Section $ * /epartmental Aut6orisation 5his section should be completed by the Head of !epartment and then the form must be passed to the +ecretary of the -aculty Doard. +igned Position /ame !ate

Section < * $aculty 2oar. Support an. A..itional Information -or leave to work flexibly, which is leave under +tatute !, II, % (c), -aculty Doard support must be clearly stated. 2opies of the relevant minute or a letter of support from the 2hairman 1 +ecretary of the -aculty Doard should be attached. *0. !oes the -aculty Doard support this application for leave> #es *5. !ate of -aculty Doard approval /o /17

Section H * $aculty Aut6orisation 5o be completed by 2hairman1+ecretary of -aculty Doard, or e"uivalent. +igned Position Complete. forms s6oul. &e sent to= )5 1our HR Sc6ool Team A.ministrator at t6e relevant a..ress=
!l. Sc6ools +chool of 7rts E Humanities +chool of the Diological +ciences +chool of the Humanities E +ocial +ciences +chool of the Physical +ciences +chool of 5echnology =7+ /on-+chool Institutions A..en&roo#e>s Hospital +chool of 2linical 4edicine

/ame !ate

;5 If applyin' from 3it6in a Sc6ool a copy of t6e form? 3it6 &ot6 (arts A @ 2 complete.? must &e sent to your Sc6ool $inance 0ana'er at t6e Sc6ool !ffice 2H I+1&0, 9ersion *, ,&1<.1,<*. Page 0 of 0