Adoptive Leave Application Form HR 108(a)
This form is to be used by employees to apply for Adoptive Leave and/or Additional Adoptive Leave. Please note
you are required to give a minimum of four weeks notice to your employer before taking Adoptive leave/ additional
adoptive leave. Please complete form in Block Capitals/Tick appropriate boxes.
HR 108(a)_V2_May 2018 Page
1 of 4 30/05/2018
1
In the case of a foreign adoption, some or all of the 4 weeks' additional adoptive leave may be taken immediately
before the date of placement
Section 1. To be completed by Employee
Surname: First Name:
Grade: Personnel No::
Location: PPS No:
Section 2. Leave Details
For Duration of each leave type please read the HSE Adoptive leave policy
Section 3.
Absence Type
Tick Start Date End Date
Adoptive Leave
Additional Adoptive Leave
Additional Adoptive
Leave
1
(Foreign adoption)
Section 4. Public Holidays
Employees absent on adoptive leave or additional adoptive leave retain leave entitlements in lieu of public holidays
which fall during such absences. You are required to take any such leave on the completion of your leave (adoptive
leave, additional adoptive leave, adoptive leave or additional adoptive leave)
Start Date End Date
Leave in Lieu of Public holidays
Section 5. Additional Information
Expected date of placement
Note: Please enclose official confirmation of expected date of placement
Section 6. Social Welfare
For staff paying Class A PRSI contributions
Please ensure that you have an made application to the Department of Employment Affairs and Social Protection
for payment of adoptive benefit (AB1 Form)
I have enclosed certification to confirm the Expected Date of Placement Please Tick
I confrim that I have read and understand the adoptive leave policy and the explanatory notes included in
Appendix 1
Signature Date
Name (Print) Contact Tel No
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Employee Name:__________________________Personnel No:__________________________
HR 108(a)_V2_May 2018 Page 2 of 4 3/20/2019
Section 7. To Be Completed By Line Manager
Checklist
All PRSI Class A Employees
Placement Cert received AB1 to Dept S.W.
Class D Officers
Placement Cert received
Average Hours worked per week (Hours to be paid on Adoptive Leave)
If this employee on a fixed term or specified purpose contract please indicate if the period of leave
applied for is covered by the tenure of their contract
Yes No
If No please provide expiry date of contract
I have checked the relevant supporting documentation requires for the leave requested and confirm that this
application complies with the terms outlined in the HSE Adoptive Leave policy
Signature
Name (Capitals) Grade
Contact Phone No Mobile No
e-mail address
Section 8. Delegated Officer Approval
Name (Print) Signature
Tel No. Date
Decision No.
Section 9. Payroll Section
Location Code
Name (Print) Signature
Tel No Date
Section 10. To Be Completed by Human Resources Personnel Administration
System updated by Name (Print)
Contact Phone No: Date
Comments
Section 10. Circulation List
1 2
3 4
5 6
7 8
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Employee Name:__________________________Personnel No:__________________________
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Appendix 1
Explanatory Notes on Adoptive Leave
HR 108(a)_V2_May 2018 Page 4 of 4 30/05/2018
The Adoptive Leave Acts 1995 and 2005 provide for the granting of adoptive leave to the following:
All adopting mothers
All sole male adopters
All adopting fathers where the adopting mother has died before or during the period for adoptive leave
or additional adoptive leave.
Adoptive Leave Entitlements
An employee is entitled to 24 consecutive weeks’ (paid) adoptive leave.
An employee is also entitled to take 16 weeks’ (unpaid) additional adoptive leave immediately after the end of
ordinary adoptive leave.
In the case of a foreign adoption, some or all of the 16 weeks’ additional adoptive leave may be taken immediately
before the date of placement.
Notification Requirements
An employee must give notice in writing, at least 4 weeks before the expected day of placement of the child, of his /
her intention to take adoptive leave. If the day of placement is postponed the leave may be postponed until the new
day of placement.
An employee must give at least 4 weeks’ notice in writing of his/her intention to take additional adoptive leave.
Payment while on Adoptive Leave
While the adoptive leave legislation does not protect the employee’s entitlement to remuneration, the health service
operates an adoptive pay scheme as follows:
All employees on adoptive leave are entitled to their basic pay plus normal fixed allowances less any adoptive
benefit to which they may be entitled on foot of their social welfare contributions. This does not include additional
amounts due to nightwork, overtime, shiftwork, working unsociable hours, standby or on-call allowances.
Employees are required to make the necessary claims for adoptive benefit to the Department of Employment Affairs
and Social Protection within the required time limits and to comply with whatever requirements are laid down by that
Department as a condition of claiming benefit.
No payment is made in respect of additional adoptive leave.
As per the Department of Employment Affairs and Social Protection information on Adoptive Benefit and the rules
around Payment Abroad, EU citizens (and citizens of Norway, Iceland, Liechtenstein or Switzerland)can get
Adoptive Benefit for any period of their adoptive leave spent in another EU country (or in Norway, Iceland,
Liechtenstein or Switzerland). EU and non EU citizens can holiday abroad and get Adoptive Benefit for a maximum
of 6 weeks while away. To get Adoptive Benefit while abroad, you need to inform DEASP Adoptive Benefit section
of your intended absence
Attendance at Pre-adoption Classes and Meetings
Adopting parents are entitled to time off during work hours without loss of pay to attend preparation classes and
pre-adoption meetings with social workers/ Health Service Executive officials required during the adoption process2
An employee is required give notice to his/her Department Head as soon as is reasonably practicable but not later
than 2 weeks before the date of the first class/meeting. An employee is required to submit documentation to
confirm the date(s) and time(s) of such classes/meetings.
Return to Work
An employee who has been absent on adoptive leave is entitled to return to the same job as previously held, under
the same contract of employment. An employee must give at least 4 weeks’ notice in writing of the date on which
s/he intends to return to work after adoptive leave or additional adoptive leave.
2
This applies only to pre-adoption classes and meetings within the State.
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