What's in this template?
This Flexible Working Arrangement Request Form supports a request under section 65 of the Fair Work Act 2009 and mirrors the structure of the Fair Work Ombudsman template. It reflects the 6 June 2023 amendments made by the Fair Work Legislation Amendment (Secure Jobs, Better Pay) Act 2022 which strengthened the right to request, introduced an obligation on employers to discuss before refusing, and added a Fair Work Commission dispute pathway under section 65B.
The form covers 8 parts:
A. Eligibility — service requirement check B. Grounds for request — the statutory grounds in NES s65 (including pregnancy as a standalone ground from 2023) C. Change requested — type of change, specifics, proposed start, duration, role impact D. Employee declaration and signature E. Discussion — record of the genuine discussion before any response F. Employer response — granted, granted with variations, or refused on reasonable business grounds G. Dispute resolution pathway — internal review, then Fair Work Commission under s65B H. Manager sign-off — counter-signed by the senior manager or practice principal
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{{practice_name}},{{employee_name}},{{position_title}},{{employment_type}}{{start_date}},{{manager_name}},{{request_date}},{{internal_review_contact}}- Signature blocks at the end of Part D and Part H
Who can request flexible work?
Under NES section 65 (as amended), an eligible employee can request a change in their working arrangements if they:
- Service requirement — are a permanent employee with at least 12 months of continuous service, or a long-term casual employee engaged on a regular and systematic basis for at least 12 months with a reasonable expectation of ongoing employment, AND
- One of the listed grounds applies:
- Are the parent, or have responsibility for the care, of a child of school age or younger
- Are a carer (within the meaning of the Carer Recognition Act 2010)
- Have a disability
- Are 55 years of age or older
- Are experiencing family and domestic violence
- Provide care or support to an immediate family or household member experiencing family and domestic violence
- Are pregnant (added as a standalone ground by the 2023 amendments)
What changed in 2023?
The Secure Jobs Better Pay Act 2022 amendments commenced on 6 June 2023 and substantially strengthened the regime:
- Genuine discussion required. Before refusing a request, the employer must discuss the request with the employee and genuinely try to reach agreement (NES s65A(3))
- Reasons must be substantive. Refusal is only permitted on reasonable business grounds and the written response must set out the specific grounds and any alternatives the employer considered (s65A(5) to (6))
- 21-day response window. The employer must give a written response within 21 days of receiving the request (s65A(1))
- Dispute pathway to the FWC. Under new section 65B, an unresolved dispute can be referred to the Fair Work Commission for conciliation, mediation, or arbitration. The FWC has power to make orders, including orders requiring the arrangement to be granted
The previous regime allowed refusal with limited procedural obligations. The current regime puts real procedural and substantive obligations on the employer.
What are "reasonable business grounds"?
Under NES s65A(5), reasonable business grounds include (without limitation):
- The new arrangements would be too costly
- Other employees' working arrangements could not be changed to accommodate the request
- It would be impractical to change other employees' working arrangements, or to recruit new employees, to accommodate the request
- The new arrangements would likely result in a significant loss in efficiency or productivity
- The new arrangements would likely have a significant negative impact on customer service (for healthcare, this is patient or participant service)
Generic statements ("it doesn't suit us") are not sufficient. The grounds must be specific, evidence-based, and tied to the actual request. The 2023 amendments and subsequent FWC decisions make clear that a paper-thin refusal will not survive scrutiny.
Who needs this form?
Every Australian healthcare practice that employs staff under the national workplace relations system. Flexible work requests are common in healthcare:
- General practices — practice nurses balancing school hours, GPs reducing days
- Allied health practices — practitioners returning from parental leave, condensing into longer days
- NDIS providers — support workers managing carer responsibilities or returning from parental leave
- Pharmacies, pathology, and diagnostic imaging providers
- Aged care providers, private hospitals, and community health services
How to customise this form
- Download and replace every
{{placeholder}}with the practice details - Issue the form to employees on request or proactively as part of the staff handbook
- Acknowledge receipt immediately when an employee returns Parts A to D — sign Part D as acknowledgement
- Diary the 21-day response deadline the moment the request is received
- Schedule the discussion in Part E — this is required before any decision to refuse
- If refusing, document the specific reasonable business grounds in Part F and the alternatives considered — generic refusals are at risk of being overturned by the FWC
- If granting (with or without variations), attach Part F to the employee's contract as a variation
- File the completed form in the personnel file. Retain for at least 7 years under Fair Work Regulations 2009 r3.42
Related templates and tools
- Staff Orientation and Induction Checklist — references the right to request and the 21-day response in the Week 1 walk-through
- Position Description Template — used to assess whether the requested arrangement can deliver the role's responsibilities
- Annual Performance Review Template — may surface a flexible work request as part of the wellbeing check-in
- Workplace Bullying, Harassment and Sexual Harassment Policy — relevant if a request is linked to a family and domestic violence ground
- Staff Confidentiality and Privacy Agreement — relevant where remote work is part of the request
Frequently asked questions
Does an employee have a right to flexible work?
They have a right to request flexible work under NES section 65 if they satisfy the service requirement and one of the grounds. The employer has a corresponding obligation to consider the request genuinely and respond in writing within 21 days. Refusal is only permitted on reasonable business grounds.
How long do we have to respond?
21 days from receipt of the request (NES s65A(1)). Diary the date the request was received and the response date the same day.
Can we refuse a flexible work request?
Yes — but only on reasonable business grounds set out in s65A(5), and only after discussing the request with the employee and genuinely trying to reach agreement. The written response must set out the specific grounds and the alternatives considered. Refusals that don't meet these requirements are at risk of being referred to the FWC under s65B.
What if there is no business case for the specific arrangement requested but there is for a variation?
Offer the variation in Part F under "granted with agreed variations". The discussion in Part E is designed to surface those compromises. The FWC is more likely to support an employer who offered a genuine alternative than one who simply refused.
Can the employee refer a refusal to the Fair Work Commission?
Yes. Under NES section 65B (in force from 6 June 2023), an employee can apply to the FWC to deal with a dispute about an employer's refusal. The FWC can conciliate, mediate, and — by agreement or where the FWC considers it appropriate — arbitrate. The FWC can make orders, including orders that the requested arrangement be granted in whole or in part.
Does this apply to casual employees?
Yes, for long-term casuals — employees engaged on a regular and systematic basis for at least 12 months with a reasonable expectation of ongoing employment. The form's Part A captures both pathways.
Is the employee required to give us medical information?
No. The grounds are status-based (carer, disability, age 55+, pregnancy, etc.). The employee should explain how the ground applies but is not required to provide medical detail. Where a workplace adjustment for disability is part of the request, the employer may request information relevant to making the adjustment — but only what is genuinely needed.
What if the request comes from an employee returning from parental leave?
Pair this form with the practice's return-from-parental-leave process. Section 65 covers parental flexible work requests, and the additional 'pregnancy' ground supports requests during pregnancy. Note the separate right under FW Act section 84 to return to the pre-parental-leave position.
How long do we keep flexible work requests?
At least 7 years after the end of employment under Fair Work Regulations 2009 r3.42. If granted, the variation forms part of the employment contract and is retained alongside the contract.