[{"id":"4b48a4b3-8662-4d4d-9d36-94dba5c628be","order":1,"text":"TIME OFF FOR DEPENDANTS","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"7233d17f-f362-49b4-8eea-c016678048f6","order":2,"text":"Request and Record Form","fontSize":"16","textAlign":"center","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"1aeebc59-2885-4618-8ec5-f0c86b6f1d94","order":3,"text":"(Statutory time off to care for dependants — section 57A, Employment Rights Act 1996)","fontSize":"11","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"c9eabd1c-3d68-4995-8623-a605542134c4","order":4,"text":"BETWEEN","fontSize":"14","textAlign":"center","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"dad8e861-1787-4728-be74-6c7e0e7f2442","order":5,"text":"[Employer / organisation name], whose place of business is at [Employer address] (the "Employer");","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f8f2c24a-50c5-4465-b39b-5b581e74396b","order":6,"text":"AND","fontSize":"14","textAlign":"center","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"aaab2f9d-8edd-442a-9ef6-a80a94d33461","order":7,"text":"[Employee full name], employed as [Job title] in the [Department / team] (payroll / employee reference [Employee reference]) (the "Employee").","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"ff3f17f2-137d-43b8-9a54-3bedb83492cc","order":8,"text":"1. PURPOSE OF THIS FORM","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","sectionNum":"S01"},{"id":"bd75579e-030f-4013-ab18-55cfb9e7316a","order":9,"text":"This form records a request by the Employee for time off to deal with an emergency or unforeseen matter involving a dependant, the Employer's response to that request, and the dates agreed. It is intended to confirm in writing what has been agreed for the purposes of payroll, handover and resource planning, and to avoid any later dispute as to what was authorised.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b9fedecb-66cd-48b7-8361-42f66133a775","order":10,"text":"In this form, 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 as an employee, tenant, lodger or boarder), or a person who reasonably relies on the Employee for assistance or for making care arrangements, in accordance with section 57A of the Employment Rights Act 1996.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"a5c37590-2123-4455-8bfd-afc01b2d5411","order":11,"text":"2. STATUTORY BASIS","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","sectionNum":"S02"},{"id":"f8ce3432-ee7b-4e58-9648-4ffea5830b4d","order":12,"text":"An employee is entitled under section 57A of the Employment Rights Act 1996 to take a reasonable amount of unpaid time off during working hours in order to take action which is necessary to deal with an unexpected event affecting a dependant, including to provide assistance when a dependant falls ill, gives birth, is injured or assaulted; to make arrangements for the provision of care for a dependant who is ill or injured; in consequence of the death of a dependant; because of the unexpected disruption or termination of care arrangements; or to deal with an unexpected incident involving the Employee's child during school hours.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"079ca947-0e2d-40e7-a294-65e750daecda","order":13,"text":"This right is a right to deal with the immediate emergency and to put longer-term arrangements in place; it is not a right to provide ongoing care personally. The Employee must tell the Employer the reason for the absence as soon as reasonably practicable and, except where this is not possible until afterwards, how long the absence is expected to last.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"adea2b0c-cc53-4fb5-9c40-f518b128cadd","order":14,"text":"3. DETAILS OF THE REQUEST","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","sectionNum":"S03"},{"id":"9b229263-ae4a-4921-89dd-b6b73af1e4e1","order":15,"text":"The Employee, [Employee full name], requests time off to deal with a matter concerning [Dependant name], who is the Employee's [Relationship to the employee].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"815796f8-333b-4531-a81f-2136147fc216","order":16,"text":"Nature of the emergency or unforeseen matter: [Describe the reason for the leave].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3fbe4840-ef47-4f80-8dcd-956b763d7a85","order":17,"text":"The Employee notified the Employer of the need for time off on [Date / time notified], by telephone.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"d116dea4-41d4-4218-93a9-2561314ec455","order":18,"text":"Time off requested: from [Start date] to [End date], being approximately [Number of days] working day(s) and [Number of hours] hour(s) in total.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"5edd166a-b003-4d44-9397-f4300cb86bc5","order":19,"text":"4. EMPLOYER'S RESPONSE","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","sectionNum":"S04"},{"id":"f0aae31a-f545-474a-bcdc-4e43679efac0","order":20,"text":"Having considered the request, the Employer, acting by [Manager / approver name], APPROVES the time off as requested. The Employee is authorised to be absent for the dates set out in clause 3 above, totalling [Number of days] working day(s).","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"approved","type":"add","operator":"="}]},{"id":"69a9eac6-83a8-4a6b-954d-3b51bd14b99a","order":21,"text":"Having considered the request, the Employer, acting by [Manager / approver name], APPROVES the time off in part only. The dates and duration authorised are as recorded below, which shall prevail over the duration requested above.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"partial","type":"add","operator":"="}]},{"id":"088f6062-b748-4b23-baae-50247b109ee9","order":22,"text":"Having considered the request, the Employer, acting by [Manager / approver name], is unable to authorise this absence as statutory time off for dependants for the reason set out below. This does not prevent the Employee from requesting annual leave or other leave to which the Employee is entitled, or from raising the matter through the Employer's leave or grievance procedures.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"add","operator":"="}]},{"id":"092a6654-0db3-4f13-a42a-ac187b611a71","order":23,"text":"Reason: [Reason for declining].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"add","operator":"="}]},{"id":"a60a71b1-13e8-488c-b587-6cc684a2a621","order":24,"text":"5. PAY TREATMENT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}],"sectionNum":"S05"},{"id":"f7aab62c-afe6-4ab5-a9bd-8ab9eaa9dc51","order":25,"text":"The time off recorded in this form shall be treated as unpaid. Where the time off is unpaid, the Employer will make the corresponding adjustment to the Employee's pay in the next available payroll run. The Employee's continuity of employment and all other contractual rights are unaffected by taking statutory time off for dependants.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}]},{"id":"30b5deeb-234c-44d7-9e3a-99a006c66970","order":26,"text":"6. RECORD OF AGREED TIME OFF","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}],"sectionNum":"S06"},{"id":"8f78da55-23bc-4577-a6fa-435cbd1684f1","order":27,"text":"Authorised absence start: [Start date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}]},{"id":"ebb33764-cfb9-4c78-b086-2f0b6ec986f6","order":28,"text":"Total authorised: [e.g. 2 days / 1.5 days].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}]},{"id":"bedcb0a1-2b13-42c1-ad74-d82172c62931","order":29,"text":"Expected return to work: [Return-to-work date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}]},{"id":"9b3419fa-af32-4f56-b404-d2798a7c6eda","order":30,"text":"Handover / cover arrangements during the absence:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}]},{"id":"0160fda5-b77a-4909-8445-b6bea6dcbf79","order":31,"text":"[Handover and cover arrangements].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"610ef9f5-9bc8-40a6-885f-fd656684be3c","value":"declined","type":"remove","operator":"="}]},{"id":"c13aff01-e80d-4efe-a6bd-1a9ffd351c8f","order":32,"text":"7. NOTE ON RECURRING ABSENCES","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","displayConditions":[{"field":"b62adee7-f9fb-47af-ad4e-52b553eab03f","value":"1","type":"add","operator":"="}],"sectionNum":"S07"},{"id":"0f18afe8-5ac8-4983-b591-94498b96247f","order":33,"text":"The parties record that the Employee's circumstances may give rise to further short periods of time off of a similar nature. [Note any agreed approach for recurring absences]. Nothing in this note limits the Employee's statutory right to take a reasonable amount of time off for dependants on each occasion that the statutory conditions are met, nor does it constitute a warning or any form of disciplinary action.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b62adee7-f9fb-47af-ad4e-52b553eab03f","value":"1","type":"add","operator":"="}]},{"id":"f4de47ea-bfc8-4e9b-9b7e-21b01b088686","order":34,"text":"8. CONFIRMATION AND DATA PROTECTION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","sectionNum":"S08"},{"id":"e5788326-f5e4-4b5d-b3b6-5efed7de009a","order":35,"text":"The Employee confirms that the information given above is true and that the time off was needed to deal with a matter concerning a dependant. The Employer confirms that this form records its decision on the request.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"3bdae921-22ff-4129-bd14-97205f133e7c","order":36,"text":"Any personal data recorded on this form (including any information relating to the health of a dependant) will be processed by the Employer solely for the purpose of administering the absence, payroll and the Employer's records, will be kept secure and confidential, and will be retained only for so long as is necessary for those purposes and to comply with the Employer's legal obligations, in accordance with the UK General Data Protection Regulation and the Data Protection Act 2018.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"3a334d9e-591c-43d5-8c1f-b0219f949442","order":37,"text":"9. STATUS OF THIS FORM AND GOVERNING LAW","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10","sectionNum":"S09"},{"id":"e7e72729-e1d0-4ba4-b33f-7b7de7df5305","order":38,"text":"This form is a record of a statutory entitlement and of the Employer's response to a request. It does not vary the Employee's contract of employment and does not exclude or limit any statutory right. Where there is any conflict between this form and the Employer's written leave policy, the policy and the Employee's statutory rights shall prevail.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"212e6317-f90b-4e00-94b6-ff4b8908d7ac","order":39,"text":"This form and any question relating to it are governed by the law of England and Wales, and the parties submit to the jurisdiction of the Employment Tribunals and the courts of England and Wales. The Employer's leave policy applicable to this request is [Policy name / reference].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"3c68cd38-1f0a-426e-92ff-0cdae3344181","order":40,"text":"Signed at [Place] on [Date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"marginTop":"10"},{"id":"97f42592-3898-4e2b-9317-bdfcd5ddbffa","order":41,"text":"For the Employee:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"ca2ab236-caa9-4f87-a5e8-b7baa4a7cf95","order":42,"text":"Name: [Employee name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"74281758-c8e5-4759-99e0-d2e76394ea24","order":43,"text":"Signature: ____________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"d1e291a0-06d1-4309-934c-d97c3915b4f9","order":44,"text":"For the Employer:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"6","cflou":false,"active":true},{"id":"f789ea2b-a661-4765-9fd8-595cd5b56e88","order":45,"text":"Name: [Manager / approver name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"f41bd0f0-7d44-4867-8135-b0731f234428","order":46,"text":"Signature: ____________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"6","cflou":false,"active":true}]