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Hr-108-m-serious-physical-assault-scheme-leave-form HR108m Serious Physical Assualt Scheme form

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Serious Physical Assault Scheme Leave
Application Form – HR 108 (m)
Please complete in Block Capitals/Tick appropriate boxes, Date fields format DDMMYYYY
HR 1
08 (m)_V2 Apr 2010 Page 1 of 3 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 Leave as a result of a serious physical assault by a patient/client incurred in the
course of my duties.
Date of assault:
Incident Report Completed: Yes
Signature Date:Y
Section 2. To be completed by the Line Manager
I confirm that the above named is entitled to the leave requested.
Incident Report Noted Yes
Assault on Duty Full Pay (should not exceed 6 months) Yes No
No of Calendar
days
Assault on Duty 1
st
Extension (should not exceed 3 months) Yes No
No of Calendar
days
Assault on Duty 2
nd
Extension (should not exceed 3 months) Yes No
No of Calendar
days
Application Approved Yes No
Signature: Date:
Name: Grade:
Contact Phone No: Mobile No:
Email Address:
Section 3. Delegated Officer Aproval
Name(Print) Signature
Tel No Date
Decision No
Section 4. To be completed by Human Resources Personnel Administration
System Updated by: Name:
Contact Phone No: Date:
Comments:
Section 4. Circulation List
1 2
3 4
5 6
Appendix 1
Explanatory note on
Serious Physical Assault Scheme Leave
HR 108 (m)_V2 Apr 2010 Page 2 of 3 Revised 01/04/2010
All employees who are absent from work as a result of a serious physical assault by a
patient/client incurred in the course of their duties are covered by the Serious Physical Assault
Scheme. Payment is conditional on the assault occurring in the actual discharge of the
employee’s duties and without his/her own default.
The scheme provides as follows:
a) Full pay based on the earnings an employee would have earned if still at work and working
the hospital/community approved roster.
b) Such full pay which would include basic pay, allowances and premium earnings may be
paid for a period of up to:
6 months for officer grades
3 months for general support staff.
c) Payment made under (b) above shall be reduced by the amount of social welfare benefit to
which the employee is entitled arising from absence due to the injury.
(d) Salary paid to an employee in the circumstances outlined above will not affect an employee’s
entitlement under the sick pay scheme.
Special Extensions for Nurses
In the case of nurses the following special extensions to the above scheme apply:
First Special Extension
A medical assessment to review the employee’s progress should be carried out no later than six
(6) weeks into the period of absence. If it is unlikely that the employee will be fit to return to work
within the six-month period covered by the scheme or immediately thereafter, but there remains a
reasonable expectation that the employee will return to work, a First Special Extension may be
granted up to a maximum period of three months.
Second Special Extension
A medical assessment to review the employee’s progress should be carried out no later than six
(6) weeks into the first special extension. If it is unlikely that the employee will be fit to return to
work during the three-month period covered by the First Special Extension or immediately
thereafter, but there still remains a reasonable expectation that the employee will return to work, a
further final extension may be granted. The second special extension provides for basic pay only
and is for a maximum period of three months.
Refer to the Revised Serious Physical Assault Scheme for Nurses (2001) for further details on the
operation of the scheme.
Employee’s Entitlements following Expiry of Payment under the Serious Physical
Assault Scheme
Officer Grades
Following expiry of an employee's entitlement to six months' pay under the Serious Physical
Assault Scheme, an employee may be granted sick pay in accordance with the provisions of the
normal sick pay scheme for officer grades. If the employee eventually exhausts their entitlement
to full pay under the normal sick pay scheme and is still unfit to resume work, consideration may
be given at that stage to applying the 5/6ths injury grant, subject to the provisions of the relevant
superannuation scheme.
General Support Grades
Following expiry of an employee's entitlement to three months' pay under the Serious Physical
Assault Scheme, an employee may be granted sick pay in accordance with the provisions of the
normal sick pay scheme for general support staff. If the employee eventually exhausts their
entitlement to payment under the normal sick pay scheme and is still unfit to resume work,
consideration may be given at that stage to applying the 5/6ths injury grant, subject to the
provisions of the relevant superannuation scheme.
Note
In the case of all employees, payment of the injury grant should be conditional on the employee
undergoing medical reviews at appropriate intervals to determine their capability to resume work
and to identify appropriate measures to facilitate the employee's return to work.
Hospital Expenses
Expenses incurred in respect of hospital /medical charges will be recouped as follows:
(a) A refund of expenditure incurred in respect of treatment provided by the Irish Public Health
Service.
(b) General Practitioner Casualty and Consultant visits
(c) Prescription charges
Employees are obliged to claim under medical insurance schemes where appropriate (e.g. V.H.I.
Refund of Drug Schemes, etc) and any payments made in respect of hospital/medical expenses
will be solely in respect of excess expenditure by the individual. Payments made under this
scheme do not confer any admission of liability on the part of the employer.
HR 108 (m)_V2 Apr 2010 Page 3 of 3 Revised 01/04/2010
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Completed 15 May 2020

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