Critical Illness Application Form HR113
This form is to be used to make an application for extended paid sick leave under the
Critical Illness Protocol (HSE HR Circular 014/2018 applies)
Please complete in Block Capitals/Tick appropriate boxes
HR 113 V2 November 2018 Page 1 of 4 25/01/2019
Section 1. To be completed by the Employee
(In exceptional circumstances application for extended paid sick leave may be submitted by a Manager on behalf of the employee)
Surname:
First Name:
PPS
Number
Date of
Birth
Grade
Personnel
Number
Place of Work
I wish to apply for extended paid sick leave From Date
I attach a medical certificate from my treating Consultant Yes
Date
Contact Tel No:
Section 2. To be completed by the Line Manager
Applicant has been referred to Occupational Health
Yes
Please attach all relevant reports
Has Occupational Health advised that the Critical Illness Protocol criteria are met Yes No
Please provide date of last review by Occupational Health
I recommend that this application is:
Approved
Rejected
Signature
Date
Name (Print)
Grade
Contact Tel No
E-Mail Address
Section 3. To be completed by the Senior Manager of service/function (at a minimum
of Grade VIII level)
I recommend this application is:
Approved
Rejected
If approved, approved on the grounds of:
Occupational Health
Recommendation
Exceptional circumstances
(management discretion)
If recommended for approval on management discretion grounds, please state reason (see Note 1):
If recommended for rejection on management discretion grounds, please state reason (see Note 2):
Signature
Date
Name
Grade
Contact Tel No
E-Mail Address
If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 113 V2 November 2018 Page 2 of 4 25/01/2019
Note: As the Decision Maker it is your responsibility to write to employees whose CIP
applications have been refused on Management Discretion grounds briefly
summarising the matters that were considered (see Note 2).
Done
Section 5. To be completed by the Line Manager
Note as the line manager it is your responsibility to:
1. Advise the applicant that their application has been approved / rejected (noting that the Senior HR decision
maker will write to the employee in respect of CIP applications refused on management discretion grounds).
If Rejected:
2. Advise employee of right of appeal
If approved:
3. Make the appropriate arrangement to have the employee paid
Done
4. Monitor the sick leave of the employee during the period
Done
5. E-mail copy of form to local Employee Relations
Done
6. E-mail copy of form to HR Department
Done
Signature
Date
Section 4. To be completed by the Employee Relations Manager or Senior HR
Decision Maker of Hospital Group, CHO or corporate/national function at a minimum
of Grade VIII level. (Employee Relations Managers who currently fulfil the role of senior HR decision
maker in CIP applications should continue to do so)
I approve this application
I refuse this application
Reason for refusal:
I hereby authorise the line manager to initiate the extension of paid sick leave under the critical illness protocol
From
Signature
Date
Name
Grade
Contact Tel No
E-Mail Address
If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 113 V2 November 2018 Page 3 of 4 25/01/2019
Section 6. SAP HR System Updated (if application is approved)
Infotype 2001 Absences Updated
Done
Subtype 0207
Done
Signature
Date
Note 1: An overview of the reasons for recommending approval or rejection on Management
Discretion grounds will assist the Senior HR decision maker with his or her decision.
Note 2: Under 2.2 of the CIP Managerial Discretion Guidelines (See Appendix B, HSE HR Circular
014/2018), managers are required to communicate the decision in writing to the employee, briefly
summarising the matters that were considered. A summary of this information and the reasons for
the decision should be captured on Section 3 of the CIP application form. This information can be
used in communicating to employees whose application for CIP has been rejected.
Note 2: There are two grounds for appeal for employees under the CIP: appeal of the medical
decision and appeal under the Management Discretion provisions. Further details are set out in
HSE HR Circular 014/2018 and in the Frequently Asked Questions Document (Appendix 3 of
Circular 014/2018). When applications for CIP are refused, the employee should be informed of
the right of appeal.
If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 113 V2 November 2018 Page 4 of 4 25/01/2019
Declaration under Section 51 of the Public Service Pensions (Single Scheme and
Other Provisions) Act 2012
To be completed by persons availing of Critical Illness Protocol as a member of a Public
Service Pension Scheme in Ireland with a commencement date on or after July 28
th
2012.
Please indicate if any of the following apply
1) Are you in receipt of any Retirement Benefit(s) or any Preserved Yes No
Pension / Lump Sum from any Irish Public Service Pension Scheme?
2) Are you entitled to receive any Retirement Benefit(s) or any Preserved Yes No
Pension / Lump Sum from any Irish Public Service Pension Scheme?
If you have answered yes to either (1) and/or (2) above, please complete details hereunder and
furnish a copy of any supporting documentation which you have received from any previous Irish
Public Service employers.
Irish Public Service Pension Benefit in Payment / Preserved Public
Service Pension Benefit Entitlement
Description (Benefit Type) e.g.
Current/Preserved Occupational
Pension and/or Retirement Lump Sum
Annual Gross Pension Value
Annual Preserved Pension Value
Number of Years of Accrued
Pensionable Service
Paying Authority
I hereby declare that the information provided above is complete and correct.
Signed: ___________________________ Name: _____________________________
(Block Capitals)
PPS No:*__________________________ Date: ______________________________
*If you have more than one PPS Number, please provide all of your PPS Numbers.
Critical Illness Protocol
Declaration
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