20 March 2020
Appendix C: COVID-19 SELF DECLARATION FORM FOR SPECIAL LEAVE WITH PAY FOR PUBLIC
HEALTH SERVICE EMPLOYEES
This form should be read in conjunction with HSE HR Circular 012/2020 click here
Employee Details
First name
Surname
Grade
Department/Location
Business Unit/Service
Area
Dates of Special Leave with Pay for COVID-19 related self-isolation/self-quarantine
Number of days advised to self-
isolate/self-quarantine
Commencing on (DD/MM/YYYY)
Starting back at work on
(DD/MM/YYYY)
Advised to self-isolate/self-quarantine by ()
GP
HSE
Hospital
Other (please specify)
______________________
Advice received via ()
Telephone
Letter/email/text (please attach
copy to this form)
In person
Other (please specify)
_________________________
20 March 2020
Details of Advice to Self-Isolate/self-quarantine
Name of adviser
(e.g. name of GP,
HSE worker)
Date and time
advice given
Details provided to
the adviser by you
(e.g. places and
dates of exposure
etc.)
Declaration
I have read and understand the provisions of Special Leave with Pay as set out
in HSE HR Circular 012/2020
Yes
I understand that in the event of non-compliance with the provisions of special
leave with pay (including the requirement to provide bona fide
1
confirmation of
self-isolation/diagnosis/self-quarantine of COVID-19) existing procedures,
including disciplinary measures may be invoked.
Yes
I understand that any overpayment of salary which may arise from non-
compliance with the provisions of special leave with pay will be repaid.
Yes
I have attached relevant documentation (where applicable)
Yes
Employee signature
Date
Manager Approval
Manager signature
Date
1
Bona fide in relation to a representation or communication means in good faith and well founded in fact. The
employer reserves the right to request further confirmation.
Data Protection
The data requested in this form will be used to process your application for Special Leave with Pay
(COVID-19 related) and will be retained as part of your personnel record for the appropriate period of
time. The employer will treat all information and personal data you give according to the law.
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signature
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dd mmm yyyy
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signature
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dd mmm yyyy
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