Compassionate Leave
Application Form HR 108 (d)
This form is to be used by employees to apply for Compassionate Leave. Please complete form in Block
Capitals/Tick appropriate boxes
HR 108 (d)_V3 Sept 2014 Page 1 of 2 Revised 01/09/2014
To be completed by the employee
Surname:
First Name:
Grade:
Personnel No:
Location:
PPS No:
I hereby notify my employer that I was required to take Compassionate Leave in accordance with the provisions of
the HSE Terms and Conditions of Employment (Revised) May 2009
Relationship of deceased to employee:
Father Mother Brother Sister
Father in law Mother in law Child Spouse
Date of Death:
No of days leave applied for?
Date From
Date to
Signature:
Date
To be completed by the Line Manager
I have checked the relevant supporting documentation required for the leave requested and confirm that the leave
required complies with the terms outlined in the relavant HR policy
Application Approved: Yes No
Signature:
Date:
Name:
Grade:
Contact Phone No:
Mobile Phone No:
e-mail address:
To be completed by Human Resources Personnel Administration
System Updated by:
Name:
Contact Phone No:
Date:
Comments:
Circulation List
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Appendix 1
Explanatory note on Compassionate Leave
HR 108 (d)_V3 Sept 2014 Page 2 of 2 Revised 01/09/2014
1. The provisions regarding special leave with pay which may be granted to an employee in
the event of the death of a relative are up to a limit of:
Five working 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.
Three working 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 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 paragraph 1, special leave with pay in excess of the
limits prescribed above may be granted at the discretion of the employer.
4. Compassionate leave is granted only at the time of the bereavement to facilitate the
employee with time off from work and cannot be granted retrospectively where it occurs
during days when an employee is not normally scheduled to work.
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