Covid-19 Flexible Work Arrangements Flexible Work Arrangement Form Question Title * 1. Employee Name Question Title * 2. Usual work location Question Title * 3. Name of your Manager / Supervisor Question Title * 4. Reason for request Required to self-quarantine on medical or government advice (evidence of advice required – please attach when submitting this form) Compromised health which increases risk of complications due to COVID-19 (medical confirmation required - please attach when submitting this form) To protect at risk family/household member (medical confirmation required - please attach when submitting this form) Care for children due to school or childcare closure and in lieu of carer’s leave Special circumstances (insert details) Question Title * 5. If available, please upload required documentation Question Title * 6. Flexible work arrangements address Question Title * 7. Flexible work arrangements contact number Question Title * 8. Period of flexible work arrangement request Start Date Date Finish Date Date Question Title * 9. I confirm that the details above are accurate and will contact my manager if they change. Yes, the details are accurate Next