This form is to be used by employees to apply for Health and Safety Leave.

Explanatory Note on Health & Safety Leave:

Pregnant employees who have recently given birth and employees who are breastfeeding may be entitled to take Health and Safety Leave in certain circumstances following completion of a risk assessment by the employer.

Where it is established that the safety or health of any pregnant employee or an employee who has recently given birth or an employee who is breastfeeding and the risk cannot be eliminated by adjusting the employees working conditions or changing working hours and no suitable alternative work can be found the employee should be granted health and safety leave.

Health and safety leave ends when there is no longer a risk to your health and safety, when breast-feeding ceases (six months limit), or at the date of the expiry of a fixed-term contract. Where a doctor certifies that it is necessary for the health and safety of the employee an employee should not be required to perform night work during the pregnancy or for 14 weeks following the childbirth.

Payment during Health & Safety Leave

An employee on health and safety leave is entitled to full basic pay plus any allowance normally paid from the employer for the first 21 calendar days of leave.

Pay does not include additional amounts an employee would receive for night-work, shift-work, overtime, working unsociable hours, standby or on-call allowances.

An employee whose health and safety leave extends beyond 21 days may be entitled to health and safety benefit from the Department of Social and Family Affairs, subject to his/her PRSI contributions.