Parental Leave
Application Form – HR 108 (j)
This form is to be used by employee
s to apply for Parental Leave
Please complete in Block Capitals/Tick appropriate boxes
Information will be input on the HR/Payroll System for the purposes of Personnel and Payroll Administration.
Date field format DDMMYY
HR 108 (j)_V2 Apr 2010 Page 1 of 3 Revised 01/04/2010
Section1. To be completed by the employee
Surname: First Name:
Grade: Personnel No:
Location: PPS No:
Name of child:
Date of birth of child:
Date of adoption order (if applicable)
Please note that this notification should be accompanied by the birth certificate or adoption order of the child.
Section 2. Please provide details of the manner in which you propose to take
Parental leave
Section 3. Please Give Details of the Duration of the proposed Parental Leave
From
To
Section 4. Date on which you propose to commence Parental Leave
Proposed commencement date
Section 5. Confirmation
I declare the information given above is true and correct. I also declare that I have read and understand all
the terms and conditions of the Parental Leave Scheme. I understand that the leave must be used for the
purpose for which it is being sought.
Signature Date
If Faxing please ensure that the Employee’s Name and Personnel Number are included on each page of the form
Name:
Personnel No:
HR 1
08 (j)_V2 Apr 2010 Page 2 of 3 Revised 01/04/2010
Section 6. To be completed by the Line Manager
I have checked the relevant supporting documentation required for the leave requested and confirm that leave
approved complies with the terms outlined in the relevant HR policy.
Application Approved (tick box) OR Application Refused (tick box)
Comments (if application is refused, state reason)
Signature Date
Name (Capitals) Grade
Contact Phone No: Mobile No:
E-mail Address
Section 7. Delegated Officer Approval
Name (Print) Signature
Tel No Date
Decision No.
Section 8. To be completed by Human Resources Personnel Administration
Is Employee in receipt of Interim payment Yes No Stop Interim payment Yes No
Payroll notified to cease interim payment Yes No Date
System Updated by: Date
Comments
Section 9. Payroll Section
Location Code
Checked by Payroll
Name (Print) Signature
Tel No Date
Section 10. Circulation List
1 2
3 4
5 6
7 8
Parental Leave Application Form – HR 108 (j)
Confirmation Document
HR 108 (j)_V2 Apr 2010 Page 3 of 3 Revised 01/04/2010
Purpose: This document is to confirm that both the Line Manager and Employee are agreeable to the
taking of Parental Leave over the course of the From and To dates and to the way in which it will be
taken, as stated below.
This document must be completed no later than four weeks before the leave is due to begin. Once this
document has been signed by both parties, it cannot be altered unless both parties agree. The applicant
must be given a copy of this confirmation document.
Section 1 To be completed by Employee
Surname: First Name:
Grade: Personnel No:
Location: PPS No:
Name of Child
Date of birth of child
Date of adoption order (if applicable)
Section 2 Confirmation Agreement
From
To
Agreed manner and duration of
Parental Leave:
Effective Period of Parental Leave
Date of commencement
Date of termination
To Be Completed by Employee
Signature Date
Name (please Print) Tel No
e-mail address Mobile No
To be completed by Line Manager on behalf of HSE
Signature Date
D D M M Y Y Y Y
Name (please Print) Tel No
e-mail address Mobile No
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