» ESA Submission: Ischemic Heart Disease, 2 Heart Attacks, 2 Stents Fitted, Biventricular Pacemaker.

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EXAMPLE 1: I have not made any previous flexible working requests. EXAMPLE 2: I have previously made a flexible working request on 1st January.

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Example: My current working pattern and role is 5 days a week as an office admin assistant.

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EXAMPLE: I would like to reduce my work hours from 35 to 30 per week.

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Example: I've been diagnosed with anxiety and I'm receiving treatment for my mental health condition. I'm finding it difficult to concentrate at the moment and I'm concerned that without changes to my work I might have an accident.

What is your working pattern and role?

Example: My current working pattern and role is 5 days a week as an office admin assistant.

Provide details of the reasonable adjustments you would find helpful and why.

EXAMPLE: a later start time so that I can miss the rush hour because I'm finding it difficult to be around lots of people

How would this adjustment benefit your employer?

EXAMPLE: This would meant that I can arrive calm and clear headed ready for work.

Please suggest how you and your employer could deal with any effects of the changes.

EXAMPLE: I would like to suggest working later into the evening to make up for the time lost .

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Migraine Reasonable Adjustments Request Template

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Repaying Debt To Your Energy Supplier

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Healthcare Professional Information Request

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ESA Submission: Ischemic Heart Disease, 2 Heart Attacks, 2 Stents Fitted, Biventricular Pacemaker.

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