Fill - Free fillable Hr-108-i-maternity-leave HR108i Maternity Leave form PDF form

Maternity Leave/Additional Maternity Leave

Application Form – HR 108 (i)

This form is to be used by employees to apply for Maternity Leave or additional Maternity Leave. Please note: You are required to give a

minimum of four weeks notice to your employer before taking Maternity Leave. Dates of Maternity Leave should be 26 weeks. Start date of

Additional (unpaid) Maternity Leave must be the day after finish date of Maternity Leave. Any additional leave e.g. Bank Holidays and Annual

Leave should be taken after Additional (unpaid) Maternity Leave finishes.

Please complete in Block Capitals/Tick appropriate boxes

HR 108(i) V4 Mar 2018 Page 1 of 4 Revised 02/01/2019

To be completed by Employee

Surname: First Name:

Grade: Personnel No:

Location: PPS No.

Absence Type Start Date End Date

Maternity Leave

Additional Maternity Leave

For Duration of each leave type please read appropriate HSE policy

Additional Information

Expected Date of Delivery

Doctor’s Name:

Doctors Stamp

Doctor’s Signature:

Note: When applying for maternity leave, please ensure your GP completes the section above or attach certification from the Department of

Employment Affairs and Social Protection.

Social Welfare

For staff paying Class A PRSI contributions

Please ensure that you have made an application to the Department of Social Protection for payment of the appropriate benefit (MB 1 Form for

Maternity Benefit) (See Appendix 1)

I have enclosed certification to confirm the expected date of delivery 

I confirm that I have read and understand the maternity leave policy and the explanatory notes included in Appendix 1 

Signature: Date:

Name: Contact Tel No:

If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form

Name:________________________ Personnel No:__________________________

HR 108(i)_V4 Mar 2018 Page 2 of 4 Revised 02/01/2019

To Be Completed By Line Manager

Checklist

All PRSI Class A Employees EDD/Placement Cert received MB1/AB1 to Dept S.W.

Class D Officers EDD/Placement Cert received

Average Hours worked per week (Hours to be paid on Maternity 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 relevant HR policy

Signature

Name (Capitals) Grade

Contact Phone No Mobile No

E-mail address

Local Payroll

Location Code

Name: Signature:

Tel No Date

To Be Completed by Human Resources

System updated by: Name:

Tel No: Date

Comments:

Circulation List

1 5

2 6

3 7

4 8

Appendix 1

Explanatory Note on Maternity Leave

HR 108(i)_V4 Mar 2018 Page 3 of 4 Revised 02/01/2019

Maternity Leave – Entitlements

Under the Maternity Protection Acts 1994 and 2004 employees are entitled to 26 weeks maternity leave. A

pregnant employee can begin and end her maternity leave on any day she selects but must take:

• a minimum of two weeks leave before the end of the expected week of confinement

• 4 weeks leave after the end of the expected week of confinement.

An employee is also entitled to take 16 weeks’ (unpaid) additional maternity leave immediately after the end

of ordinary maternity leave.

Maternity Leave – Notification Requirements

An employee must notify her Department Head of her intention to take maternity leave at least four weeks before the leave is

due to commence.

Application for additional maternity leave should be made either at the time of the initial application or in writing not later than 4

weeks before the end of the maternity leave.

If an employee changes her mind about taking maternity leave she may revoke the notice by sending a further written notice to

her Department Head.

Payment while on Maternity Leave

While the maternity protection legislation does not protect the employee’s entitlement to remuneration during maternity leave,

the health service operates a maternity pay scheme as follows:

All employees on maternity leave are entitled to their basic pay plus normal fixed allowances less any maternity 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, and stand-by or on-call allowances.)

Employees are required to make the necessary claims for maternity benefit to the Department of 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.

http://www.welfare.ie/en/pdf/mb1.pdf

Employees are also obliged to do the following:

 Notify the HSE of the actual amount of Maternity benefit they are in receipt of

 Notify the HSE of any subsequent revisions to that amount.

The HSE is not liable for any loss that an employee incurs as a result of their failure to comply with the rules governing the

granting of maternity benefit as set out by the Department of Social Protection.

Travel outside of the State

As per the Department of Employment Affairs and Social Protection information on Maternity Benefit and the rules around

Payment Abroad, EU citizens (and citizens of Norway, Iceland, Liechtenstein or Switzerland) can get Maternity Benefit for any

period of their maternity leave spent in another EU country (or in Norway, Iceland, Liechtenstein or Switzerland). EU and non

EU citizens can holiday abroad and get Maternity Benefit for a maximum of 6 weeks while away. To get Maternity Benefit while

abroad, you need to inform DEASP Maternity Benefit section of your intended absence.

Ante-Natal and Post-Natal Medical Care

An employee is entitled to time off work without loss of pay to attend ante-natal and post-natal medical visits. Time off

includes the time required to travel to and from the appointment. The employee must notify her employer in writing of the date

and time of the appointment as soon as is practicable and in any event not later than two weeks before the date of the

appointment

Appendix 1

Explanatory Note on Maternity Leave

HR 108(i)_V4 Mar 2018 Page 4 of 4 Revised 02/01/2019

Time off for Ante-Natal Classes

A pregnant employee is entitled to time off work without loss of pay to attend one set of ante-natal classes (except for the last 3

classes). This right to attend only one set of antenatal classes covers all an employee’s pregnancies while in employment.

The employee must notify her or his employer in writing of the dates and times of these classes as soon as is practicable and

in any event not later than two weeks before the first class. The employee is required to provide the appropriate

documentation outlining the dates and time of classes.

Return to Work

The employee’s right to return to work is conditional on her giving notice in writing not later than 4 weeks before the expected

return date of her intention to return to work and the expected date of return.

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