Force Majeure Leave
Notification Form – HR 108 (f)
This form must be completed by an employee who takes Force Majeure Leave as soon as
reasonably practicable after the leave is taken.
Under the Parental Leave Act, an employee is entitled to force majeure leave where for urgent family reasons,
owing to an injury to or the illness of a person referred to in section 13(2) of the Act, the employee's immediate
presence is indispensable at the place where the person is.
The persons referred to in section 13(2) of the Act are:
a person of whom the employee is the parent or adoptive parent;
the spouse of the employee or a person with whom the employee is living as husband and wife;
a person to whom the employee is in loco parentis;
a brother or sister of the employee; and
a parent or grandparent of the employee.
Force majeure leave must not exceed 3 working days in any period of 12 consecutive months or 5 working
days in any period of 36 consecutive months. Please complete form in Block Capitals/Tick appropriate boxes.
Format Date fields as DDMMYYYY
HR 108 (f)_V2 Apr 2010 Page 1 of 2 Revised 01/04/2010
Section1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS. No:
Names injured/ill
*
person
Address of injured/ill* person
Relationship to employee:
Nature of injury/illness*
No of days applied for?
Date(s) of force majeure leave
From
To
Section 2. Confirmation
I confirm that I have taken force majeure leave on the above mentioned date(s) because for urgent family
reasons, owing to the injury to/illness* of the person specified above, my immediate presence at that person's
address was indispensable.
I declare that the information given above is true and complete.
Signature: Date
*
delete as appropriate
If faxing please ensure Employee’s Name and Personnel Number are included on each page of form
Name:______________________________________Personnel No______________________
HR 108 (f)_V2 Apr 2010 Page 2 of 2 Revised 01/04/2010
Section 3. To be completed by the Line Manager
I have checked that the start and end dates specified comply with requirements and that the overall period
indicated does not exceed that which is allowed under this leave. I have examined the documentation provided
and confirm that the leave approved complies with the relevant HR policy.
Application Approved Application Refused
Comments (if application is refused, state reason)
Signature Date
Name (Capitals) Grade
Contact Phone No: Mobile No:
e-mail address
Section 4. To be completed by Human Resources Personnel Administration
System Updated By: Date
Section 5. Circulation List
1 2
3 4
5 6
7 8
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