Fillable Carers Leave Application Form HR 108 (c) (Ireland - Health Service Executive)

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Carers Leave Application Form HR 108 (c) (Ireland - Health Service Executive)

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Carers Leave
Application Form – HR 108 (c)
This form is to be used by employees to apply for Carers Leave.
Information will be input on the HR/Payroll System for the purposes of Personnel and Payroll Administration.
Please complete form in Block Capitals/Tick appropriate boxes
HR 108 (c)_V2 Apr 2010 Page 1 of 5 Revised 01/04/2010
Section 1. To be completed by the employee
Surname First Name
Grade
Personnel
Numb
er
Location PPS No
I hereby notify my employer that I propose to take Carer’s Leave in accordance with the provisions of the Carer’s
Leave Act, 2001, with effect
From
To
My request is to allow me to provide full time care and attention to:
(Please print Name here)
Section 2. Proposed Manner in which you would like to take Carers leave
One continuous period of 104 weeks
In periods of ___________________Weeks / months (each of which must be of at least
*
13 weeks
duration – the aggregate of which does not exceed 104 weeks).
Employee will be engaging in employment (up to 15 hours per week) during Carer’s Leave
Other
†
If Other please outline how you propose to take carers leave
Section 3. Confirmation
I wish to confirm that I have made an application to the Department of Social, Community
and Family Affairs for a decision of a deciding officer of that Department that ______________________ in respect
of whom I propose to take Carer’s leave, is a relevant person (i.e. is in need of full-time care and attention) for the
purposes of the Social Welfare (Consolidation) Act, 1993.
Signature Date
*
Unless otherwise agreed with the employer
†
Subject to agreement with the employer
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Name ____________________________ Personnel No._______________________
HR 108 (c)_V2 Apr 2010 Page 2 of 5 Revised 01/04/2010
Section 4. To be completed by Line Manager
I have checked the relevant supporting documentation required for the leave requested and confirm that leave
approved complies with the terms outlined in the relevant HR policy.
Application Approved (tick box) or Application Refused (tick box)
Comments (if application is refused, state reason)
Signature Date
Name (Capitals) Grade
Contact Phone No: Mobile No:
E-mail Address
Section 5. Delegated Officer Approval
Name (Print) Signature
Tel No Date
Decision No
Section 6. To be completed by Human Resources Personnel Administration
Does Incremental Date require amendment Yes No
New
Date
Is Employee in receipt of Interim payment Yes No Stop Interim payment Yes No
Payroll notified to cease interim payment Yes No Date
System Updated by: Date
Comments
Section 7. Payroll Section
Location Code
Checked by Local Payroll
Name (Print) Signature
Tel No Date
Section 8. Circulation List
1 2
3 4
5 6
7 8
Carers Leave Application Form – HR 108 (c)
Confirmation Document
HR 108 (c)_V2 Apr 2010 Page 3 of 5 Revised 01/04/2010
Purpose: This document is to confirm that both the Line Manager and Employee are agreeable to the
taking of Carer’s Leave over the course of the From and To dates and to the way in which it will be
taken, as stated below.
This document must be completed no later than four weeks before the leave is due to begin. Once this
document has been signed by both parties, it cannot be altered unless both parties agree. The applicant
must be given a copy of this confirmation document.
Section 1 To be completed by Employee
Surname First Name
Personnel
Number
PPS
Number
Section 2 Confirmation Agreement – To be completed by Employee
From
To
Agreed manner and duration of
Carer’s Leave:
Signature Date
Section 3 To be completed by Line Manager on behalf of HSE
Signature Date
Name (Print) Tel No
e-mail address Mobile No
Appendix 1
Explanatory Notes
The Carer’s Leave Act 2001 entitles employees to avail of temporary unpaid leave from
their employment to enable them to personally provide full-time care and attention for a
person who is need of such care, i.e. the relevant person. The period of leave to which
an employee is entitled is subject to a maximum of 104 weeks in respect of any one care
recipient.
An employee may work up to a maximum of 15 hours per week during carer’s leave or
may attend an educational or training course or take up voluntary or community work for
up to 15 hours per week.
Entitlement to Carer’s Leave
An employee must fulfil the following criteria before they are eligible to apply for Carer’s
Leave:
S/he must have completed at least 12 months’ continuous service with the HSE
before the commencement of the leave.
S/he must intend to take the leave for the purpose of personally providing full-
time care and attention for a person who is in need of such care for the duration
of the leave.
The person receiving full time care and attention must be objectively assessed
and deemed to be in need of full time care by a deciding officer from the
Department of Social, Community and Family Affairs.
Only one employee may be on carer’s leave in respect of any one relevant
person, at any one time.
An employee will generally not be permitted to be on Carer’s Leave in respect of
more than one relevant person at any one time. However, on one occasion only,
an employee may commence leave in respect of a relevant person, while already
on leave in respect of another relevant person, where the two relevant persons
reside together.
Manner in which Carer’s Leave may be Taken
The Act provides that the leave should be taken in one of the following ways:
One continuous period of 104 weeks; or
One of more periods, the total duration of which amounts to not more than 104
weeks.
Where the employee wishes to take Carer’s Leave over a number of broken periods the
following conditions apply:
The minimum statutory entitlement that may be taken in one period at the
discretion o the employee is 13 weeks.
An employer may refuse, on reasonable grounds given to an employee in writing,
to permit an employee to take carer’s leave for any period of less than 13 weeks.
There must be a gap of at least 6 weeks between periods of carer’s leave taken
in respect of the same relevant person.
HR 108 (c)_V2 Apr 2010 Page 4 of 5 Revised 01/04/2010
An employer and employee may agree arrangements for carer’s leave on terms
more favourable to the employee. The granting of such arrangements is at the
discretion of the HSE.
The employee is required to notify the HSE of any change of circumstances that
affect his / her entitlement to Carer’s Leave.
Notification Requirements
The granting of carer’s leave is subject to compliance with the following notification
requirements:
An employee is required to complete the Notice of Intention to take Carer’s Leave
Form and submit it to his/her Department Head at least 6 weeks before the date s/he
proposes to commence the leave (except in emergency circumstances where it is not
reasonably practicable to do so).
Upon receipt of the decision of the deciding officer (or appeals officer) from the
Department of Social, Community and Family Affairs confirming that the relevant person
has been medically certified as being in need of full time care, the employee must submit
a copy to his/her Department Head/local HR Department.
Confirmation of Carer’s Leave
A “Confirmation Document”, (which outlines the date on which the leave period will
commence and the duration of the leave period) must be completed and signed by the
Department Head and employee not less than 2 weeks before the leave is due to
commence.
Revocation of Notice
An employee who wishes to revoke the notice of his / her intention to take Carer’s Leave
must do so in writing prior to the date of the confirmation document.
Alterations to the Confirmation Document
An employer (Department Head) and an employee may agree, after the date of the
confirmation document, to postpone or curtail the leave, or vary the form in which it will
be taken. Where this occurs the confirmation document should be amended to reflect
the changes.
Return to Work
HR 108 (c)_V2 Apr 2010 Page 5 of 5 Revised 01/04/2010
An employe
e who is on Carer’s Leave must notify the employer (Department Head) of
his / her intention to return to work not less than four weeks before the date on which
that employee is due to return to work.
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Carers Leave Application Form HR 108 (c) (Ireland - Health Service Executive)

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Completed 11 April 2022

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