Pension Rate of Pay Application Form – HR 114
This form is to be used when you are making application/review of payment of pension rate of pay.
Please com
plete in Block Capitals/Tick appropriate boxes
HR 1
14_V2 Apr 2010 Page 1 of 2 Revised 01/04/2010
NOTE: Payment of Pension Rate shall be for a period of three (3) months and without prejudice to
the officer’s entitlement to resume duty at any time or retire on grounds of ill health subject to the
approval of the Health Services Executive’s Occupational Health Physician.
Section 1. To be completed by the employee
Surame: First Name:
PPS No
Date of
Birth
Grade
Personnel
Numb
er
Place of Work
Date of Cessation of Paid Sick Leave
I wish to apply for the
(tick 0ne)
Payment of pension rate of pay Extension payment of pension rate of pay
From
To
I attach a medical certificate from my Doctor / Consultant outlining the expected date of resuming duty.
Signed Date
Name (print) Contact Tel No:
Section 2. To be completed by the Line Manager
Has the applicant been referred to Occupational Health Yes No
If yes, please attach all relevant reports
Please provide date of last review by Occupational Health
Confirmation of Application Details by Line Manager.
I recommend that this application is: Approved Rejected
Signature Date
Name (Print) Grade
Contact Tel No E-Mail Address
Section 3. To be completed by the Hospital Manager/ General Manager.
I recommend this application is: Approved Rejected
Signature Date
Name Grade
Contact Tel No E-Mail Address
Section 4. To be completed by the Asst National Director of HR
I approve this application I refuse this application
Reason for refusal:
I hereby authorise the line manager to initiate the payment process associated with pension rate of pay.
From
To
Signature Date
Name Grade
Contact Tel No E-Mail Address
