Critical Illness Application Form - HR113: Section 1. To Be Completed by The Employee
Critical Illness Application Form - HR113: Section 1. To Be Completed by The Employee
Critical Illness Application Form - HR113: Section 1. To Be Completed by The Employee
This form is to be used to make an application for extended paid sick leave under the
Critical Illness Protocol (HSE HR Circular 014/2018 applies)
Please complete in Block Capitals/Tick appropriate boxes
PPS Date of
Number Birth
Personnel
Grade
Number
Place of Work
I wish to apply for extended paid sick leave From Date
I attach a medical certificate from my treating Consultant Yes
Signed Date
Name (print) Contact Tel No:
Section 2. To be completed by the Line Manager
Applicant has been referred to Occupational Health Yes
Please attach all relevant reports
Has Occupational Health advised that the Critical Illness Protocol criteria are met Yes No
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 Senior Manager of service/function (at a minimum
of Grade VIII level)
I recommend this application is: Approved Rejected
If recommended for approval on management discretion grounds, please state reason (see Note 1):
If recommended for rejection on management discretion grounds, please state reason (see Note 2):
Signature Date
Name Grade
Contact Tel No E-Mail Address
I hereby authorise the line manager to initiate the extension of paid sick leave under the critical illness protocol
From
Signature Date
Name Grade
Contact Tel No E-Mail Address
Note: As the Decision Maker it is your responsibility to write to employees whose CIP
applications have been refused on Management Discretion grounds briefly
summarising the matters that were considered (see Note 2).
Done
If approved:
4. Monitor the sick leave of the employee during the period Done
Signature Date
Signature Date
Note 2: Under 2.2 of the CIP Managerial Discretion Guidelines (See Appendix B, HSE HR Circular
014/2018), managers are required to communicate the decision in writing to the employee, briefly
summarising the matters that were considered. A summary of this information and the reasons for
the decision should be captured on Section 3 of the CIP application form. This information can be
used in communicating to employees whose application for CIP has been rejected.
Note 2: There are two grounds for appeal for employees under the CIP: appeal of the medical
decision and appeal under the Management Discretion provisions. Further details are set out in
HSE HR Circular 014/2018 and in the Frequently Asked Questions Document (Appendix 3 of
Circular 014/2018). When applications for CIP are refused, the employee should be informed of
the right of appeal.
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.
I hereby declare that the information provided above is complete and correct.
*If you have more than one PPS Number, please provide all of your PPS Numbers.