Shorter Working Year Scheme
Application Form – HR 115
This form is to be used by employees to apply for Shorter Working Year Scheme
Information will be input on the HR /Payroll system for the purposes of Personnel and Payroll Administration.
Please complete form in Block Capital/Tick appropriate boxes.
HR 115_V3 Nov 2015 Page 1 of 3 Revised 03/11/2015
Section 1. To be completed by the employee
I wish to apply for inclusion in the Shorter working Year Scheme in accordance with the terms and conditions
set out in Circular 023/2015
Surname: First Name:
Grade: Personnel No.
Date of Birth
PPS No.
Correspondence address
County: Post Code* Country
Contact Phone No: Mobile Phone No:
e-mail address:
Title of Post:
Work Location (Address)
(e.g. Hospital, PCCC
area)
I confirm that I have read and understand the terms and conditions as per Circular 023/2015 Yes No
If this is your first application have you completed one year’s continuous service with the HSE? Yes No
Date of commencement of service
Proposed Dates of Special Leave
Number of W
eeks leave required (tick one)
2 4 6 8 10 13
Payment Method required (tick one)
Special administrative arrangements (Averaged Pay)
Unpaid
From
To
From
To
From
To
Line Managers Details
Surname: First Name:
Address
Contact Phone No: Mobile Phone No:
e-mail address:
If Faxing please ensure Employee’s Name and Personnel Number are included on each page of the form
Name ____________________________ Personnel No._______________________
HR 115_V3 Nov 2015 Revised 03/11/2015
Page 2 of
3
Declaration
1. I declare that all information given by me in this application is true and complete.
2. I understand that my acceptance of the shorter working year scheme is subject to the terms outlined in
circular 023/2015.
3. I undertake that any overpayment which may arise from my participation in this Scheme will be repaid to
the HSE No later than 31
st
December of the year the special leave is taken
4.
I understand that this leave must be used for the purpose for which it is being sought
Signature Date
Section 2. To be completed by the Line Manager
Special Leave Recommended
Yes No
Signature Date
Name: Grade
Contact Phone No: Mobile No:
E-mail Address
Section 3. Senior Management Approval
Special Leave Approved
Yes No
Signature Date
Name: Grade
Contact Phone No: Mobile No:
E-mail Address
Comments (if application is refused, state why)
Important: If the application is approved this form must be returned to HR by 30
th
November.
Section 4. Delegated Officer Approval
Name (Print) Signature
Tel No Date
Decision No
Section 4. To be completed by Human Resources, Personnel Administration
Is Employee in receipt of interim payment?
Yes No
If yes has Payroll been notified to cease interim payment
Yes No
Date payroll notified to cease interim payment
System updated by Date
Payroll Notified to set up averaged pay Date
If Faxing please ensue Employee’s Name and Personnel Number are included on each page of the form
Name ____________________________ Personnel No._______________________
HR 115_V3 Nov 2015 Page 3 of 3 Revised 03/11/2015
Section 5. Payroll Section
Name: Signature
Phone No:
Section 6. Payroll Interface
Location Code
Wage Type Payroll Area
Employment Signal Date
Section 7. Circulation List
1 2
3 4
Date
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