[{"id":"442bff27-1023-4717-a5d9-fb9e8e923090","order":1,"text":"CARER'S LEAVE REQUEST AND DECISION FORM","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"0b7bddca-126f-483e-bef3-76758f3ec9f5","order":2,"text":"Statutory unpaid carer's leave — Carer's Leave Act 2023 and the Carer's Leave Regulations 2024","fontSize":"14","textAlign":"center","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"75ef54c8-36f1-4715-ac52-26b33af74142","order":3,"text":"Sections 80J to 80N, Employment Rights Act 1996","fontSize":"14","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"7333342d-5847-4231-9dd4-5f67e51137fc","order":4,"text":"This form records a request for statutory unpaid carer's leave and the employer's decision on that request. It is intended to confirm in writing the dates of any leave that is agreed, so that those dates can be reflected accurately in payroll, in handover arrangements and in resource planning, and so as to avoid any subsequent dispute as to what was agreed.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true},{"id":"25e8cde8-ba0b-411b-985b-e9e1552544b3","order":5,"text":"PART A — EMPLOYEE'S REQUEST","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"marginTop":"10"},{"id":"10d73946-1570-4e5f-9ea3-de5adfd7551c","order":6,"text":"1. THE EMPLOYEE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"6","sectionNum":"S01"},{"id":"78152a16-9526-456e-a2da-b67dc9ceab6d","order":7,"text":"Full name of employee: [Employee full name].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"622201c0-a630-423b-b49e-ec2f14a1a50d","order":8,"text":"Job title: [Job title].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"371525e7-f95d-4f28-a18e-e8081abc6ebe","order":9,"text":"Department or team: [Department or team].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"26e73b85-f4e3-47db-8a8c-505906fc918c","order":10,"text":"Staff or payroll reference number: [Staff/payroll number].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"595c100f-3dc5-4faf-b4b6-41791f89327b","order":11,"text":"2. THE EMPLOYER","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S02"},{"id":"21e2122a-40ca-48f8-9d07-0514804df991","order":12,"text":"Employer (organisation name): [Employer name] (the "Employer").","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"909cffb6-0af8-44f6-a915-dc92926b8c9f","order":13,"text":"This request is submitted to [Line manager full name], [Line manager job title], who is the employee's line manager for the purposes of this request.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"5bd6ca09-c407-4152-acbb-25eae0806025","order":14,"text":"3. THE DEPENDANT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S03"},{"id":"5fa46596-e0c8-4ef9-ae13-5360c7f07ca3","order":15,"text":"Carer's leave may be taken to provide or arrange care for a dependant with a long-term care need, as defined in section 80J of the Employment Rights Act 1996. A dependant means a spouse, civil partner, child or parent of the employee, a person who lives in the same household as the employee (otherwise than by reason only of being the employee's boarder, employee, lodger or tenant), or any other person who reasonably relies on the employee to provide or arrange care.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"7e003cd5-1112-401a-afcc-6d35e557449d","order":16,"text":"The employee's relationship to the dependant is: [Relationship to dependant].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"4e3a185a-98b5-443d-baa2-c5533241c598","order":17,"text":"4. LONG-TERM CARE NEED AND PURPOSE OF LEAVE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S04"},{"id":"65a8a0b9-7d3d-41e4-9624-c1e3224282bd","order":18,"text":"The dependant has a long-term care need on the following basis: [Basis of long-term care need].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"aabef99e-a6fc-4b34-8ea9-aab96e786620","order":19,"text":"A long-term care need exists where the dependant has a physical or mental illness or injury such that they need, or are likely to need, care for more than three months; or has a disability within the meaning of the Equality Act 2010; or requires care in connection with their old age.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"c3313244-2bed-45f5-a146-c4227b1d4901","order":20,"text":"The employee requires the leave in order to provide or arrange care for the dependant. The employee describes the purpose of the leave as follows: [Purpose of the leave]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"d59ab331-57a3-4c4e-a984-8266be386fad","order":21,"text":"The employee understands that the Employer is not entitled to require evidence in relation to the request before granting the leave, and the Employer does not require any such evidence. Nothing in this form obliges the employee to disclose any medical or other confidential information concerning the dependant beyond that which the employee chooses to provide.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"bd485acc-fb35-41d4-96bf-cf04a44cfaaf","order":22,"text":"5. AMOUNT AND PATTERN OF LEAVE REQUESTED","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S05"},{"id":"1b69d52e-0286-477d-bc00-b1973971c314","order":23,"text":"The statutory entitlement is to one week of unpaid carer's leave in any rolling period of twelve months. A "week" means the period of time the employee normally works over seven days; for a full-time employee this is ordinarily five working days. Leave may be taken as a single continuous block, as individual full days, or as half-days.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"7112a56f-3bbb-4da2-aaac-e03a4b0b3899","order":24,"text":"The employee requests to take a continuous block of one full working week of carer's leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"879caa8f-76ba-471f-b2c6-75fd412a9716","value":"Full week","type":"add","operator":"="}]},{"id":"83a4b5ef-2767-4ac2-b097-302289dbc0ab","order":25,"text":"The employee requests to take carer's leave on individual full working days.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"879caa8f-76ba-471f-b2c6-75fd412a9716","value":"Specific days","type":"add","operator":"="}]},{"id":"08a6109c-b266-4b9c-8b5f-500fe42ab38b","order":26,"text":"The employee requests to take carer's leave in half-day units, as detailed below.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"879caa8f-76ba-471f-b2c6-75fd412a9716","value":"Half-days","type":"add","operator":"="}]},{"id":"f49c6987-73da-4c2e-94be-f47a13d24da6","order":27,"text":"Details of the half-day pattern requested: [Half-day pattern details]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"879caa8f-76ba-471f-b2c6-75fd412a9716","value":"Half-days","type":"add","operator":"="}]},{"id":"c0ac2df4-c432-4d1e-9b1c-c1de53b9aee9","order":28,"text":"Total amount of carer's leave requested on this occasion: [Amount of leave requested]. The employee confirms that, taking this request together with any carer's leave already taken, the total will not exceed the one-week statutory entitlement within the current rolling twelve-month period.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"56ce7917-23cb-44df-a112-408c760cd4f6","order":29,"text":"6. DATES OF LEAVE REQUESTED","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S06"},{"id":"943e7d4d-bb85-4b9c-8389-6b2c36eb260f","order":30,"text":"Requested first day of leave: [First day of leave].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"1eb54903-7fe6-4b62-a32e-e4921a7dd908","order":31,"text":"Requested last day of leave: [Last day of leave].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"e22a0fc7-d7c7-4c20-8ed2-a17190e5fb08","order":32,"text":"Number of working days (or half-days) of leave requested in total: [Number of working days requested].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"1c6cd32f-5e60-467b-bbcb-bacfa9c23be2","order":33,"text":"7. NOTICE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S07"},{"id":"d63a56db-9308-4e5d-8477-f692e337e7db","order":34,"text":"Under regulation 7 of the Carer's Leave Regulations 2024, the employee must give notice that is at least twice as many days as the period of leave requested, or three days, whichever is the greater. The Employer may, if it wishes, waive this notice requirement.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"51be9fd2-d0cb-4f56-9171-ffed035caa74","order":35,"text":"Date on which this request is given: [Date request is given].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"d8629659-ac97-43de-9d79-2f5715fe24dd","order":36,"text":"The employee gives this notice in accordance with the statutory notice period set out above.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"86e43774-9fd4-43c4-b2bf-59689a50d34b","value":"Statutory notice","type":"add","operator":"="}]},{"id":"8b40aae4-8753-4d23-9980-b4b144d3ee49","order":37,"text":"The employee acknowledges that this request is made at shorter notice than the statutory minimum, and asks the Employer to exercise its discretion to waive the notice requirement.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"86e43774-9fd4-43c4-b2bf-59689a50d34b","value":"Shorter notice","type":"add","operator":"="}]},{"id":"dec7f496-21ea-48cd-9927-2d80eb29ccb4","order":38,"text":"8. EMPLOYEE DECLARATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S08"},{"id":"0d251882-e072-45f4-9a04-5c6b3506449c","order":39,"text":"The employee confirms that: (a) the person named above is a dependant of the employee within the meaning of section 80J of the Employment Rights Act 1996; (b) that dependant has a long-term care need; (c) the purpose of the leave is to provide or arrange care for that dependant; and (d) the leave requested does not exceed the employee's remaining statutory entitlement in the current rolling twelve-month period.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"e7c30c98-9784-4b6b-966d-8af9214a655a","order":40,"text":"The employee understands that carer's leave is unpaid, and that during the leave the employee continues to benefit from all terms and conditions of employment that would have applied but for the absence, save in respect of remuneration for the time taken.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"39195765-300e-45db-b950-4ccf5fbe234d","order":41,"text":"Signed by the employee: [Employee name (signature)].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"0745a19e-8d23-4c73-90fb-0b93fc585954","order":42,"text":"Date: [Date employee signs].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true},{"id":"ef28a4c7-4617-4c64-966e-6f043c35e10d","order":43,"text":"PART B — EMPLOYER'S DECISION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"12","cflou":false,"active":true,"marginTop":"14"},{"id":"c73ee223-da4e-44ee-82f4-6df2bee86f8d","order":44,"text":"9. STATUS OF THE REQUEST","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"6","sectionNum":"S09"},{"id":"1f1c1a6f-3adb-429d-9564-98738c39b75c","order":45,"text":"The Employer confirms that carer's leave is a day-one statutory right and that a properly made request cannot be refused. The Employer may either grant the leave on the dates requested or, where it reasonably considers that the operation of its business would be unduly disrupted, postpone the leave to a later date within one month of the requested date.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"5d7f501c-4020-41c7-8bb7-9ce518222475","order":46,"text":"This request is dealt with by [Decision-maker full name], [Decision-maker job title], on behalf of the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"3a8219ba-93d7-400f-9145-d35ac067b4e1","order":47,"text":"Decision: the request is GRANTED on the dates requested.","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Approve","type":"add","operator":"="}]},{"id":"e59514d4-8a16-44ff-b3b3-afd177c06f39","order":48,"text":"Decision: the request is POSTPONED to revised dates, as set out below.","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Postpone","type":"add","operator":"="}]},{"id":"8bb3a7c2-6be0-4b43-a71d-0b97da1c462e","order":49,"text":"10. THE EMPLOYER'S DECISION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"14","sectionNum":"S10"},{"id":"c3fbe8f0-b356-4816-b422-1ff9def7b458","order":50,"text":"Confirmation of approved leave","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true,"marginTop":"8","displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Postpone","type":"remove","operator":"="}]},{"id":"640314d5-4ae8-45d9-b9a2-d2df0f3aee56","order":51,"text":"The Employer confirms that the carer's leave described in Part A is approved and will be recorded as authorised unpaid carer's leave. The agreed leave will commence on [Approved first day] and end on [Approved last day], comprising [Approved number of working days] working day(s) of leave.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Postpone","type":"remove","operator":"="}]},{"id":"7af3fa78-e9c2-47f4-baea-1b0e7e2586b4","order":52,"text":"Payroll instruction: the period of leave above is to be recorded as unpaid carer's leave, with no deduction to continuity of employment and no effect on accrued contractual benefits other than remuneration for the days taken. Any additional payroll or handover instruction: [Payroll / handover note]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Postpone","type":"remove","operator":"="}]},{"id":"01d7b8bf-d13b-40b1-9a67-47a3f63cc4f6","order":53,"text":"Date of this decision: [Decision date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Postpone","type":"remove","operator":"="}]},{"id":"d35a9bd0-974e-4ac0-8d45-6aeb057c0807","order":54,"text":"Postponement (counter-notice)","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true,"marginTop":"8","displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Approve","type":"remove","operator":"="}]},{"id":"098068a1-7c6e-4603-934f-be51a3b82846","order":55,"text":"The Employer does not refuse the request but, in accordance with regulation 8 of the Carer's Leave Regulations 2024, postpones the leave because it reasonably considers that the operation of its business would be unduly disrupted if the leave were taken on the requested dates. The reason for the postponement is: [Reason for postponement]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Approve","type":"remove","operator":"="}]},{"id":"d91f9b3f-a824-4552-90c9-372a390aabbb","order":56,"text":"The Employer permits the employee to take carer's leave of the same duration on revised dates, commencing on [Revised first day] and ending on [Revised last day]. The Employer confirms that these revised dates fall within one month of the date originally requested.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Approve","type":"remove","operator":"="}]},{"id":"67b8c46f-29db-4a5b-9f3d-654eda573ded","order":57,"text":"This counter-notice is given within seven days of the original request. Date of this counter-notice: [Counter-notice date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"9529fc5c-e220-4a07-80b5-6c5e066214d9","value":"Approve","type":"remove","operator":"="}]},{"id":"47ac56f2-cd2a-4011-9f59-e37ab1b9f41c","order":58,"text":"11. SIGNATURE ON BEHALF OF THE EMPLOYER","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"14","sectionNum":"S11"},{"id":"de849837-b5c8-4bc3-b5cf-887540738845","order":59,"text":"Signed for and on behalf of the Employer: [Decision-maker name (signature)].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"efb8f2f9-5276-445e-adeb-fa34f8163ac0","order":60,"text":"Job title: [Decision-maker job title (signature)].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f4d4bc57-355e-478d-92a6-db7f157d3871","order":61,"text":"Date: [Date signed by employer].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"14","cflou":false,"active":true},{"id":"91a102cb-0f64-4016-bbfb-08b71a1a8899","order":62,"text":"12. STATUTORY PROTECTIONS","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S12"},{"id":"507c90d5-ea9d-4e36-8a45-9fb97d1647b5","order":63,"text":"The employee has the right not to be subjected to any detriment, and not to be dismissed, for a reason connected with taking or seeking to take carer's leave; any such dismissal is automatically unfair. Where the employee considers that the Employer has unreasonably postponed, prevented or attempted to prevent the taking of carer's leave, the employee may present a complaint to an employment tribunal within the time limits prescribed by law.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true},{"id":"ab950d97-8356-4a6d-b159-ded0c8d45b11","order":64,"text":"This form is governed by the law of England and Wales and is to be construed in accordance with the Carer's Leave Act 2023, the Carer's Leave Regulations 2024 and the Employment Rights Act 1996. Nothing in this form limits any greater contractual entitlement the employee may have under any policy of the Employer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true}]