Temporary Rehabilitation Remuneration Form–HR114
This form is to be used to make an application or request an extension/or review of payment of Temporary
Rehabilitation Remuneration (TRR). HSE HR Circular 005/2014 applies.
Please complete in Block Capitals/Tick appropriate boxes
HR 114b July 2014 Page 1 of 3 23/06/2015
Section 1. To be completed by the Employee
Surname: First Name:
PPS No
Date of
Birth
Grade
Personnel
Number
Work Address/Location
Home Address
Land-Line or Mobile No. Personal email address
Date of Cessation of Paid Sick Leave
I wish to apply for the
(Tick one)
Payment of TRR Extension payment of TRR
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, failure to do so will result in delayed payment.
If no, please state reason
Please provide date of last review by Occupational Health
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
If rejected please state reason
Signature Date
Name Grade
Contact Tel No E-Mail Address
If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 114b July 2014 Page 2 of 3 23/06/2015
Section 5. To be completed by the Line Manager
Note as the line manager it is your responsibility to:
1. Advise the applicant that their application has been approved / rejected /extended
If approved:
2. Request pensions management to calculate the applicable TRR Done
3. Notify employee of the rate of TRR to be paid Done
4. Make the appropriate arrangement to have the employee paid Done
5. Monitor the sick leave of the employee during the period Done
6. Advise relevant departments of all adjustments. Done
7. E-mail copy of form to local Personnel Records
Done
8. E-mail copy of form to local Employee Relations Done
Signature Date
Section 6.SAP HR System Updated (if application is approved)
Infotype 2001 / subtype 0220 Absences Updated Done
Wagetype 0051 Infotype 0008 Done
Signature Date
Section 4. To be completed by the Employee Relations Manager (or equivalent HR Manager at
General Manager level in areas without an ERM)
I approve this application I refuse this application
Reason for refusal:
I hereby authorise the line manager to initiate the payment process associated with TRR.
From To
Signature Date
Name Grade
Contact Tel No E-Mail Address
If Faxing please ensure Employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No._________________
HR 114b July 2014 Page 3 of 3 23/06/2015
Declaration under Section 51 of the Public Service Pensions (Single Scheme and
Other Provisions) Act 2012
To be completed by persons availing of a Temporary Rehabilitation Remuneration as a
member of a Public Service Pension Scheme in Ireland with a commencement date on or
after July 28
th
2012.
Please indicate if any of the following apply
Yes No
1) Are you in receipt of any Retirement Benefit(s) or any Preserved
Pension / Lump Sum from any Irish Public Service Pension Scheme?
2) Are you entitled to receive any Retirement Benefit(s) or any Preserved Yes No
Pension / Lump Sum from any Irish Public Service Pension Scheme?
If you have answered Yes to either (1) and/or (2) above, please complete details hereunder and
furnish a copy of any supporting documentation which you have received from any previous Irish
Public Service employers.
Irish Public Service Pension Benefit in Payment / Preserved Public
Service Pension Benefit Entitlement
Description (Benefit Type) e.g.
Current/Preserved Occupational
Pension and/or Retirement Lump Sum
Annual Gross Pension Value
Annual Preserved Pension Value
Number of Years of Accrued
Pensionable Service
Paying Authority
I hereby declare that the information provided above is complete and correct.
Signed: ___________________________ Name: _____________________________
(Block Capitals)
PPS No:*__________________________ Date: ______________________________
*If you have more than one PPS Number, please provide all of your PPS Numbers.
Temporary Rehabilitation
Remuneration Declaration
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