Bereavement Leave
Application Form HR 108 (d)
This form is to be used by employees to apply for Bereavement Leave. Where applicable,
lease complete Online, print off, sign , scan and forward to your local processing unit.
HR 108 (d)_V3 NOV 2019 Page 1 of 2 Revised 06/11/2019
Personnel No:
I hereby notify my Manager that I am applying to take Bereavement Leave in accordance with the
provisions of HSE HR Circular 029/2019
Father Mother Brother Sister
Father in law Mother in law Child Spouse
Date From : Date to :
To be completed by the Line Manager
I have checked the relevant supporting documentation required for the leave requested and confirm that
the leave complies with the provisions outlined in HSE HR Circular 029/2019
Application Approved: Yes No
Contact Phone No:
E-mail address:
Date :
No. of days leave applied for?
Date of Death:
Relationship of deceased to employee:
PPS No: Location:
First Name: Surname:
To be completed by the employee
Date From:
No. of days leave approved:
Date To:
If leave is not approved, state reason:
HR 108 (d)_V3 NOV 2019 Page 2 of 2 Revised 06/11/2019
1. Bereavement Leave may be granted to an employee in the event of the death of a relative
up to a limit of:
(A) Twenty working days (twenty eight calendar days) in the case of a spouse (including a
cohabiting partner), child (including adopted children and children being cared for on the
basis of 'in loco parentis') or any person in a relationship of domestic dependency, including
same sex partners;
(B) Five working days (seven calendar days) in the case of other immediate relatives as
follows: father, mother, brother, sister, father in law, mother in law.
2. In exceptional circumstances (e.g where the employee concerned has lived in the same
house as the deceased or has to take charge of the funeral arrangements) an employee may
be granted up to three working days' special leave on the death of a more distant relative.
3. In a case where an employee has to travel abroad to make funeral arrangements in respect
of a relative specified in 1 (A) or (B), special leave with pay in excess of the limits prescribed
above may be granted at the discretion of the employer.
4. The granting of Bereavement Leave and the amount granted will depend on whether or not
the employee was scheduled/rostered to work for the period in question. Bereavement leave
is granted only at the time of the bereavement to facilitate the employee with time off from
work and is not granted retrospectively where it occurs during days / shifts when an
employee is not normally scheduled/rostered to work.
Further information on bereavement leave is outlined in HSE HR Circular 029/2019. https://
Explanatory Note on Bereavement Leave
Appendix 1
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