Form FFWO1 "Request for Flexible or Predictable Working Arrangement" - City and County of San Francisco, California

What Is Form FFWO1?

This is a legal form that was released by the Department of Human Resources - City and County of San Francisco, California - a government authority operating within California. The form may be used strictly within City and County of San Francisco. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Department of Human Resources - City and County of San Francisco, California;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FFWO1 by clicking the link below or browse more documents and templates provided by the Department of Human Resources - City and County of San Francisco, California.

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Download Form FFWO1 "Request for Flexible or Predictable Working Arrangement" - City and County of San Francisco, California

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City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
www.sfdhr.org
Human Resources Director
Request for Flexible or Predictable Working Arrangement
Form Instructions
Information about the Family Friendly Workplace Ordinance
The Family Friendly Workplace Ordinance (FFWO) is a local City and County of San Francisco (City) ordinance that allows
employees to request flexible or predictable working arrangements in order to assist with caregiving responsibilities for:
1) a child or children for whom the employee has assumed parental responsibility; 2) a person or persons with a serious
1
2
health condition
in a family relationship
with the employee; or 3) a parent aged 65 or older of the employee.
Employees can request changes in the terms and conditions of their employment that would provide flexibility or
scheduling predictability to assist with caregiving responsibilities. Requests may include, but are not limited to, changes
in the employees’ terms and conditions of employment as they relate to:
1) The number of hours the employee is required to work;
2) The times when the employee is required to work;
3) Where the employee is required to work;
4) Work assignments or other factors; or
5) Predictability in a work schedule.
3
An employee may make up to two requests in a 12-month period, unless the employee experiences a major life event
,
4
in which case the employee may make an additional request
during that timeframe. Also, if the department revokes a
5
flexible or predictable working arrangement the employee may submit an additional written request
.
An employee’s request for a flexible or predictable schedule may be denied:
6
If the employee hasn’t been working for the City for at least six months
7
If the employee doesn’t regularly work at least eight hours per week
8
If the employee works in a job classification that has been exempted from the FFWO
9
For a bona fide business reason
, including, but not limited to:
1. The identifiable cost of the change in a term or condition of employment requested in the application,
including, but not limited to, the cost of productivity loss, retraining or hiring employees, or transferring
employees from one facility to another
2. Detrimental effects on the ability to meet customer or client demands
3. The inability to organize work among other employees
4. The insufficiency of work to be performed during the time the employee proposes to work.
1
See Section 12Z.3 of the FFWO of the FFWO FAQ for definition.
2
See Section 12Z.3 of the FFWO of the FFWO FAQ for definition.
3
See Section 12Z.3 of the FFWO of the FFWO FAQ for definition.
4
Section 12Z.4(e)
5
Section 12Z.5(d)
6
Section 12Z.4(a)
7
Section 12Z.4(a)
8
Section 12Z.11
9
Section 12Z.5(c)
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
www.sfdhr.org
Human Resources Director
Request for Flexible or Predictable Working Arrangement
Form Instructions
Information about the Family Friendly Workplace Ordinance
The Family Friendly Workplace Ordinance (FFWO) is a local City and County of San Francisco (City) ordinance that allows
employees to request flexible or predictable working arrangements in order to assist with caregiving responsibilities for:
1) a child or children for whom the employee has assumed parental responsibility; 2) a person or persons with a serious
1
2
health condition
in a family relationship
with the employee; or 3) a parent aged 65 or older of the employee.
Employees can request changes in the terms and conditions of their employment that would provide flexibility or
scheduling predictability to assist with caregiving responsibilities. Requests may include, but are not limited to, changes
in the employees’ terms and conditions of employment as they relate to:
1) The number of hours the employee is required to work;
2) The times when the employee is required to work;
3) Where the employee is required to work;
4) Work assignments or other factors; or
5) Predictability in a work schedule.
3
An employee may make up to two requests in a 12-month period, unless the employee experiences a major life event
,
4
in which case the employee may make an additional request
during that timeframe. Also, if the department revokes a
5
flexible or predictable working arrangement the employee may submit an additional written request
.
An employee’s request for a flexible or predictable schedule may be denied:
6
If the employee hasn’t been working for the City for at least six months
7
If the employee doesn’t regularly work at least eight hours per week
8
If the employee works in a job classification that has been exempted from the FFWO
9
For a bona fide business reason
, including, but not limited to:
1. The identifiable cost of the change in a term or condition of employment requested in the application,
including, but not limited to, the cost of productivity loss, retraining or hiring employees, or transferring
employees from one facility to another
2. Detrimental effects on the ability to meet customer or client demands
3. The inability to organize work among other employees
4. The insufficiency of work to be performed during the time the employee proposes to work.
1
See Section 12Z.3 of the FFWO of the FFWO FAQ for definition.
2
See Section 12Z.3 of the FFWO of the FFWO FAQ for definition.
3
See Section 12Z.3 of the FFWO of the FFWO FAQ for definition.
4
Section 12Z.4(e)
5
Section 12Z.5(d)
6
Section 12Z.4(a)
7
Section 12Z.4(a)
8
Section 12Z.11
9
Section 12Z.5(c)
th
One South Van Ness Avenue, 4
Floor ● San Francisco, CA 94103-5413 ● (415) 557-4800
Section by Section Instructions:
These instructions will help you correctly complete the Request for Flexible or Predictable Working Arrangement form.
You must complete all sections of this form to request a flexible or predictable working arrangement, request
reconsideration of a previously denied request, amend a currently approved arrangement, or request the renewal of a
currently approved arrangement. Each approval is valid for a maximum of 12 months.
Section 1 pertains to you and your current employment with the City. Be sure to indicate whether the request is
new, is for reconsideration of a previously denied request, or is a renewal of a currently approved request.
Section 2 pertains to the nature of your relationship with the person(s) for whom you are seeking a flexible or
predictable working arrangement.
Section 3 pertains to the flexible or predictable working arrangement you are seeking.
If your request is due to a need to provide care to a family member with a serious health condition, your request must
include a completed “Verification of Caregiving Responsibilities” form.
After completing sections one through three and signing and dating the request form, submit the request, along with a
“Verification of Caregiving Responsibilities” form if necessary, to your department’s human resources manager. A
meeting will be scheduled to discuss your request within 21 calendar days of your submission of the form. You will
receive a written response to your request within 21 calendar days of this meeting. Should your request be denied, you
have the right to request reconsideration under section 12Z.6 of the FFWO:
Section 12Z6: Request for Reconsideration by Employee from the Denial of Request for Flexible or Predictable Working
Arrangement.
a) An employee whose request for a flexible or predictable working arrangement has been denied may submit a
request for reconsideration to the employer in writing within 30 days of the decision.
b) If an employee submits a request for reconsideration under this section, the employer must arrange a meeting
to discuss this request to take place within 21 days after receiving the notice of the request.
c) The employer must inform the employee of the employer’s final decision in writing within 21 days after the
meeting to discuss the request for reconsideration. If the request for reconsideration is denied, this notice must
explain the employer’s bona fide business reason for denial.
Resource Materials
Visit the Office of Labor Standards Enforcement’s (OLSE) FFWO
webpage
for more information on the FFWO.
Read the Department of Human Resources
FAQ
for answers to frequently asked questions about the FFWO.
FFWO1 (Rev. 10/2017)
Page 2 of 3
City and County of San Francisco
Department of Human Resources
Carol Isen
Connecting People with Purpose
www.sfdhr.org
Human Resources Director
Request For Flexible Or Predictable Working Arrangement
Type of Request:
New
Reconsideration
Renewal
Section 1: Employee Information
Name: ____________________________________________ Phone Number: __________________________________
Address: ___________________________________________________________________________________________
Email Address: ______________________________________________________________________________________
Class No. & Title: _____________________________________Department: ____________________________________
Section 2: Flexible or Predictable Working Arrangement
I am requesting a flexible or predictable working arrangement that is different from my current working schedule/
arrangement pursuant to the rights provided under Section 12Z.4 of the Family Friendly Workplace Ordinance. By
signing and submitting this form I confirm that I meet each of the following eligibility criteria:
I have been an employee of the City and County of San Francisco for six months or more.
I work at least eight hours per week on a regular basis.
I have, or expect to have, caregiving responsibilities for (select only one):
A child or children under age 18 for whom I have assumed parental responsibility;
A person or persons with a serious health condition with whom I have a familial relationship; or
A parent aged 65 or older.
Name of family member for whom arrangement is sought: __________________________________________________
Family member date of birth: ___________________ Relationship to employee: ________________________________
If your request is due to a need to provide care to a family member with a serious health condition, your request must
include a completed “Verification of Caregiving Responsibilities” form. Have you included the required verification with
this request (if needed)?
Yes
No
Section 3: Proposed Flexible or Predictable Working Arrangement
Arrangement requested from (dates): ______________________ to ______________________ (12-month maximum)
Specify arrangement requested (e.g. days/hours/times/location worked, reduction or change in duties, notice of
schedule): _________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Explain how requested arrangement relates to caregiving:___________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I declare that the information I have provided above is true and correct. I understand that any false statements made on
this form are subject to disciplinary action, up to and including termination.
Employee Signature _____________________________________________________ Date ________________________
FFWO1 (Rev. 10/2017)
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