Work From Home Request Form With a Safety Check

The form itself

A static copy of the finished form, exactly as it renders. Nothing here can be filled in or submitted, so read it as a reference and build your own from the button above.

Request to work from home

One form for a regular arrangement, a trial, or a fixed block of weeks. Your manager answers in writing within twenty one days, and a refusal comes with the reasons rather than a one line no.

You and what you are asking for

Your name *

First

Last

Employee number *

Your team *

Your manager's email *

Which days are you asking for? *

Monday

Tuesday

Wednesday

Thursday

Friday

It varies week to week

You would like to start on *

For how long? *

Why are you asking? *

The work itself

The strongest requests are specific about which parts of the job travel and which do not. A manager is being asked to predict whether the work still gets done, and the person who already knows the answer is you.

Which parts of your job work better away from the office, and which are worse? *

Are there days you must be on site? *

No

Yes, a fixed day each week

Yes, but it moves

Only for particular meetings

How would people reach you? *

Same hours, same channels

Same hours, calls by appointment

Shifted hours, described above

Where you would actually work

The company's health and safety duty does not stop at the office door. When you work from home, that space is a workplace for the hours you are working in it, and an injury there can be a workers compensation matter. That is why this section exists, and it is why an honest answer is more useful than a tidy one. Nobody is inspecting your house; you are confirming that the place you work is safe enough to work in.

My home workspace *

I have a set place to work rather than moving around the house

The desk and chair let me sit with my screen at eye height and my feet flat

There is enough light to work without straining, and no glare across the screen

Cables and leads are out of the walkway

There is a working smoke alarm on that level

I can take a call without being overheard by somebody outside my household

Somebody would notice within a few hours if I had an accident during the day

A photo of the space you would work in

Upload photo

One photo, taken from the doorway so the desk, the chair and the window are all in it. It is not an inspection, and nobody is looking at your kitchen. It is the fastest way to sort out an obvious problem, such as a laptop on a dining chair, before it becomes six months of back pain.

Your internet connection *

Fixed line, reliable

Fixed line, drops occasionally

Mobile broadband

Shared with others during the day

Who else is at home during your working hours? *

Nobody

Adults, working themselves

Children in care elsewhere

Children at home in my care

Equipment

What do you already have at home?

Company laptop

Second screen

Adjustable chair

Headset

Desk at working height

Docking station

Printer or scanner

What would you need, if this is agreed?

How it would be reviewed

An arrangement is easier to agree when it has an end you can both see. Naming the review date yourself removes the fear that saying yes means saying yes forever, and it gives you a scheduled moment to ask for more rather than a conversation you have to start from nothing.

Review it on *

If the full request is declined, would a smaller one work? *

Yes, fewer days

Yes, a shorter trial

Yes, different days

No, it is this or nothing

Anything else your manager should know

Every field, and what it collects

The complete field list, in the order respondents meet it.

Your nameNameRequired
Employee numberShort textRequired
Your teamDropdownRequired: Options: Claims · Underwriting · Customer contact · Broker relationships · Finance · Technology · People and culture
Your manager's emailShort textRequired
Which days are you asking for?Multiple choiceRequired: Options: Monday · Tuesday · Wednesday · Thursday · Friday · It varies week to week
You would like to start onDateRequired
For how long?DropdownRequired: Options: A three month trial, then review · An ongoing arrangement · A fixed block of weeks, ending below · One off, for a specific reason
Why are you asking?Long textRequired
Which parts of your job work better away from the office, and which are worse?Long textRequired
Are there days you must be on site?Single choiceRequired: Options: No · Yes, a fixed day each week · Yes, but it moves · Only for particular meetings
How would people reach you?Single choiceRequired: Options: Same hours, same channels · Same hours, calls by appointment · Shifted hours, described above
My home workspaceMultiple choiceRequired: Options: I have a set place to work rather than moving around the house · The desk and chair let me sit with my screen at eye height and my feet flat · There is enough light to work without straining, and no glare across the screen · Cables and leads are out of the walkway · There is a working smoke alarm on that level · I can take a call without being overheard by somebody outside my household · Somebody would notice within a few hours if I had an accident during the day
A photo of the space you would work inPhoto upload: One photo, taken from the doorway so the desk, the chair and the window are all in it. It is not an inspection, and nobody is looking at your kitchen. It is the fastest way to sort out an obvious problem, such as a laptop on a dining chair, before it becomes six months of back pain.
Your internet connectionSingle choiceRequired: Options: Fixed line, reliable · Fixed line, drops occasionally · Mobile broadband · Shared with others during the day
Who else is at home during your working hours?Single choiceRequired: Options: Nobody · Adults, working themselves · Children in care elsewhere · Children at home in my care
What do you already have at home?Multiple choice: Options: Company laptop · Second screen · Adjustable chair · Headset · Desk at working height · Docking station · Printer or scanner
What would you need, if this is agreed?Long text
Review it onDateRequired
If the full request is declined, would a smaller one work?Single choiceRequired: Options: Yes, fewer days · Yes, a shorter trial · Yes, different days · No, it is this or nothing
Anything else your manager should knowLong text

What makes this form work

It asks which parts of the job get worse, not just better

One question, both halves. A request that admits handovers and coaching are worse at home reads as somebody who has thought about it, and it gives the manager the shape of a compromise instead of a yes or no.

The safety check is seven things a person can actually confirm

A set place to work, screen at eye height, light without glare, leads out of the walkway, a smoke alarm, somewhere to take a call, and somebody who would notice an accident. Each one is observable from where they are sitting, which is what separates a real self check from a policy tick.

The photo turns a paragraph into thirty seconds

One shot from the doorway, with the field description explaining exactly that and promising nobody is looking at the kitchen. It catches the laptop on the dining chair while it is still cheap to fix, and it is one of the few classic fields whose help text a respondent actually sees.

Questions people ask

Why does a work from home form ask about the house?

Because for the hours somebody is working there, it is a workplace, and the employer's duty of care and its workers compensation exposure both follow. The form is not an inspection, which is why the section is worded as a self check the employee confirms. Skipping it entirely is what leaves both sides unprotected when somebody trips over a lead at eleven in the morning.

Should the form ask why somebody wants to work from home?

Ask, but do not require a personal reason. Some requests carry extra protection when they are tied to caring responsibilities, disability, age or family violence, and a form that never invites the reason quietly denies people that route. The field here explains that and leaves the level of detail to the person filling it in.

What does the review date change?

It changes the answer more often than anything else on the form. A manager weighing an open ended commitment is deciding forever; a manager agreeing to a three month trial with a date on it is deciding for three months. The field is required for that reason, and the option to accept a smaller arrangement sits next to it.

Can the manager reply through this form?

No, and it is better that they do not. This form is the request and its record. The decision belongs in writing to the employee, which is what most flexible work provisions require, along with the reasons where the answer is no. Use the email alert add on so the request reaches the manager the moment it is submitted.

Build your own in about a minute

The button below opens the generator with this use case already described. Change the wording to match your own, generate, then edit anything you like.

Make my work from home request form

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