Special Absence Authority
Health and Safety Leave Application Form – HR 108 (g)
This form is to be used by employees to apply for Health and Safety Leave.
HR 108 (g)_V2 Apr 2010 Page 1 of 2 Revised 01/04/2010
Section 1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS. No:
In accordance with the provisions of the HSE Terms and Conditions of Employment (Revised) 2009.I hereby notify
my employer that I wish to apply for Health & Safety Leave as I am: (please () relevant box(es) below
Pregnant Recently given birth Brestfeeding
From date
To date
Name of employee’s Doctor:
Signature Date
Section 2. To be completed by the Line Manager
I confirm that the above named is entitled to the leave requested.
Workplace Risk Assessment
completed
Yes
Nightwork Risk Assessment
compl
eted
Yes
Employee’s Doctor has certified that nightwork poses a risk to the employees health an safety Yes No
Application Approved Yes No
Signature: Date
Name: Grade:
Contact Phone No: Mobile No:
Email Address:
Section 3. To be completed by Human Resources Personnel Administration
System Updated by: Name:
Contact Phone No: Date:
Comments:
Section 4. Payroll Section
Location Code
Checked by Local Payroll
Name (Print) Signature
Tel No Date
Special Absence Authority
Health and Safety Leave Application Form – HR 108 (g)
This form is to be used by employees to apply for Health and Safety Leave.
HR 108 (g)_V2 Apr 2010 Page 2 of 2 Revised 01/04/2010
Explanatory Note on Health & Safety Leave:
Pregnant employees who have recently given birth and employees who are breastfeeding may be
entitled to take Health and Safety Leave in certain circumstances following completion of a risk
assessment by the employer. Where it is established that the safety or health of any pregnant
employee or an employee who has recently given birth or an employee who is breastfeeding and
the risk cannot be eliminated by adjusting the employees working conditions or changing working
hours and no suitable alternative work can be found the employee should be granted health and
safety leave. Health and safety leave ends when there is
no longer a risk to your health and
safety, when breast-feeding ceases (six months limit), or at the date of the expiry of a fixed term
contract. Where a doctor certifies that it is necessary for the health and safety of the employee an
employee should not be required to perform night work during the pregnancy or for 14 weeks
following the childbirth.
Payment during Health & Safety Leave
An employee on health and safety leave is entitled to full basic pay plus any allowance normally
paid from the employer for the first 21 calendar days of leave. Pay does not include additional
amounts an employee would receive for night-work, shift-work, overtime, working unsociable
hours, standby or on-call allowances.
An employee whose health and safety leave extends beyond 21 days may be entitled to health
and safety benefit from the Department of Social and Family Affairs, subject to his/her PRSI
contributions.
Section 5. Circulation List
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