Jury Service Leave
Application Form – HR 108 (h)
This form is to be used by employees to apply for Jury Service Leave.
Please complete in Block Capitals/Tick appropriate boxes
Section 1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS No.
I hereby notify my employer that I have been called for Jury Service and hereby apply for Jury Service Leave in
accordance with the provisions of the HSE Terms and Conditions of Employment (Revised) May 2009
Number of days called for Jury Service:
From date
To date
Signature: Date
Section 2. 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
If no, give
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:
Section 4. Circulation List
1 2
3 4
5 6
7 8
HR 1
08 (h)_V2 Apr 2010 Page 1 of 2 Revised 01/04/2010
Appendix 1
Explanatory Note on Jur
y Service Leave
The Juries Act, 1976 provides that every citizen aged between 18 and 70 years who is entered in
the Dail Electoral Register may be called for jury service, with the following exceptions:
Certain professional categories are excused as of right, including:
 Nurses;  Dentists;  Pharmacists; and  Medical Practitioners
An employee who has served (or attended to serve) on a jury in the previous three years may be
excused by the county registrar. A judge may also excuse a juror from service for a period of
Employers have a duty to allow employees to attend for jury service. However, if it is not possible
due to service requirements to allow the employee to attend, s/he may be granted a certificate
from the appropriate manager, stating that it would be contrary to the public interest for him/her to
serve as a juror because s/he performs essential and urgent services of public importance that
cannot reasonably be performed by another or postponed.
HR 108 (h)_V2 Apr 2010 Page 2 of 2 Revised 01/04/2010
An employee
is treated as employed during any period s/he is complying with a jury summons.
Thus, an employee is entitled to pay (basic plus any regular allowances e.g. long-term acting up
and continuous location allowances) and continues to accrue entitlements to annual leave,
incremental credit, etc, while on jury service.
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