BSO HR Family Leave Application

Step 1 of 3

Welcome to the Family Leave Application Forms

This form will allow you to complete the following applications:

- Maternity Leave

- Paternity Leave

- Adoption Leave

- Shared Parental Leave

For any queries please complete the BSO HR Query Form to contact the Pay and Conditions Team : HR Query Form

For Guidance on calculating your Annual Leave please refer to the HR Portal: Annual Leave Calculators

For all the Family Pack information please refer to the Portal for our Policy: Family Pack Policy

Your Personal Information

Your Name(Required)

First Last

Your Email Address Work(Required)

This should be your HSC email address

Your Email Address Personal(Required)

This is the email address we will issue your letter to

Your Line Manager's Email Address(Required)

Please ensure this is correct as your line manager must receive a copy of this form in order to approve the application.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number(Required)

Work Details

Staff Number(Required)

This can be found on your payslip

Band / Grade(Required)

Job Title(Required)

Organisation(Required)

Date of entry to service(Required)

ALB Directorate(Required)

PHA Directorate(Required)

SPPG Directorate(Required)

BSO Directorate(Required)

Are you currently on a Trust Payroll or BSO?(Required)

Please select HSC Trust(Required)

HSC Location(Required)

Leave Application

What Leave Application are you submitting?(Required)

Maternity Leave

MAT B1 Upload from Registered GP/Midwife

If you do not currently have this please forward a scanned copy to BSO.PayandConditions@hscni.net as soon as possible.

Drop files here or

Accepted file types: jpg, png, pdf, word, jpeg, Max. file size: 20 MB, Max. files: 4.

Expected Date of Confinement (EDC)(Required)

Do you intend to return to work following your Maternity Leave?(Required)

If no, please submit this form as soon as possible. * Please note that it is a condition of receiving paid maternity leave that you return to work for a minimum period of three months after expiry of leave and if you fail to return to work, you may be liable to refund such amount of this maternity pay received as indicated in the Terms and Conditions of Service.

*If NO, you can continue to the end of the application form and click SUBMIT

Date intended to start Maternity Leave(Required)

Please note that an employee on maternity leave who wishes to return to work before end of the 39 weeks leave must give 28 days' notice in writing of the date of return to work

Additional Unpaid Maternity Leave(Required)

Staff with one year’s service at the beginning of the eleventh week before EDC will be entitled to an additional 13 weeks unpaid maternity leave. While we realise that at this stage you may not be completely sure as to whether you wish to take a further 13 weeks additional unpaid leave, it would be helpful if you would indicate the following:

How many weeks leave to you intend to take unpaid?(Required)

It will be assumed that you intend to take the additional 13 weeks additional unpaid leave unless you advise the Human Resources Department otherwise. Please note that if you intend to return to work before 52 weeks has expired you must advise the Human Resources Department in writing at least 28 days before your expected return to work.

Pay Options

Occupational maternity pay may be paid as a combination of full and half pay, or as a fixed amount spread equally over the maternity leave period.

Please indicate below your payment preference:(Required)

(Please note that OMP only can be spread equally over a 26, 39 or 52 week period. SMP cannot be spread or re-profiled. Please contact Human Resources for further guidance.)

Please state how you would like your OMP spread

DECLARATION(Required)

I hereby declare that the information given above is correct and that I meet the criteria set for Maternity Leave in full. Please sign your name below:

Date Signed(Required)

Paternity Leave

Please state how do you intend to take your paternity leave(Required)

Please see the Paternity Leave and Pay (Maternity Support) information pack for details on eligibility criteria and rates of pay. It is presumed you will take 2 weeks paternity leave, unless you indicate otherwise.

Expected Date of Childbirth(Required)

Please specify the dates you wish to take paternity leave(Required)

Do you have any other comments in relation to your request for paternity leave?(Required)

DECLARATION(Required)

I hereby declare that the information given above is correct and that I meet the criteria set for Paternity Leave in full. Please sign your name below:

Date Signed(Required)

Adoption Leave

Date on which matching was notified(Required)

On what date will the child be placed with you(Required)

Is the child to be newly matched for an approved adoption agency?(Required)

Upload Matching Certificate

If not available please forward to BSO.PayandConditions@hscni.net as soon as possible.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, word, Max. file size: 20 MB, Max. files: 10.

Section A

Do you intent to return to work following your Adoption Leave?(Required)

Please note that it is a condition of receiving paid adoption leave that you return to work for a minimum period of three months after expiry of leave and if you fail to return to work, you may be liable to refund such amount of this adoption pay received as indicated in the Terms and Conditions of Service.

*If no please submit this form to the Human Resources Department as soon as possible.

Section B

Date intended to start Adoption Leave(Required)

Adoption leave may start 11 weeks before your child placement.

Please note that an employee on adoption leave who wishes to return to work before the end of their 39 weeks leave must give 28 days’ notice in writing of the date he/she wants to return to work.

Section C

Additional Unpaid Adoption Leave(Required)

Staff with one year’s service at the beginning of the eleventh week before placement date will be entitled to an additional 13 weeks unpaid adoption leave.

While we realise that at this stage you may not be completely sure as to whether you wish to take a further 13 weeks additional unpaid leave, it would be helpful if you would indicate the following:

How many weeks do you intend to take?(Required)

Payment Options

Occupational adoption pay (OAP) may be paid as a combination of full and half pay, or as a fixed amount spread equally over the adoption leave period. Please indicate below your payment preference:

Payment Preference(Required)

Please note that OAP only can be spread equally over a 26, 39 or 52 week period. Statutory Adoption Pay (SAP) cannot be spread or re-profiled. Please contact Human Resources for further guidance.

Please state how you would like your OMP spread

DECLARATION(Required)

I hereby declare that the information given above is correct and that I meet the criteria set for Adoption Leave in full. Please sign your name below:

Date Signed(Required)

Shared Parental Leave Application

This form should be filled in by employees with a child due to be born or adopted on or after the 5th April 2015, to indicate their intention to take Shared Parental Leave (ShPL) to share the caring responsibilities for the child. The form provides the Organisation with an early indication of your intentions for consideration and must be submitted at least eight weeks prior to the start date of the first period of SPL along with the curtailment notice (included in Section B) which effectively brings a period of maternity leave or adoption leave to an end early so that the remaining entitlement to maternity/adoption leave can be used as ShPL and can be taken and shared between the parents. If the employee is not the mother/main adopter, their partner will be required to submit a curtailment notice to their own employer.

Employees should read the Shared Parental Leave Policy in full prior to completing this form and seek advice form HR if they are unclear about whether they meet the requirements.

Section A

State if you are the mother/main adopter or the partner or the mother/main adopter(Required)

Name of the other parent/partner(Required)

Child’s expected date of birth/date of placement for adoption(Required)

Child’s actual date of birth/date of placement for adoption (if known)(Required)

Start date of mother/main adopter’s maternity/adoption leave (or pay period*)(Required)

*If the mother/main adopter is not entitled to maternity/adoption leave, state the start and end dates of maternity/adoption or the maternity allowance period.

End date of mother/main adopter’s maternity/adoption leave (or pay period*)(Required)

Section B: Employee Notice of Curtailment of Maternity/Adoption Leave

Please complete this section if you are the mother or main adopter. The curtailment notice effectively brings a period of maternity leave or adoption leave to an end early so that the untaken portion of entitlement to maternity/adoption leave can be taken as ShPL. You must take into account that a minimum of two weeks compulsory maternity/adoption leave must be taken by the mother/main adopter.

As stated above, you must provide at least eight weeks’ notice of your curtailment date.

I wish my maternity/adoption leave to end on the following date:(Required)

Signed by Employee(Required)

I hereby declare that the information given above is correct and that I meet the criteria set for Shared Parental Leave in full. Please sign your name below:

Date Signed(Required)

Section C : Shared Parental Leave Details - Notice of Entitlement

Please check eligibility requirements in the Shared Parental Leave Policy.

This section of the form is intended for you to indicate how you and the other parent (if eligible) would like to take the remaining weeks of leave, once some of the 52 weeks of maternity or adoption leave have been taken and then curtailed.

For example, if the mother takes 10 weeks of maternity leave, there will be 42 weeks remaining to share between eligible parents. This is an indication at this stage and does not become binding unless you intend it to be, in which case you should also submit the next Form – Booking Notice (Notice to Take Leave).

Total number of weeks ShPL available (52 weeks minus the amount already taken or intended to be taken)(Required)

Total number of weeks you (the employee) intended to take(Required)

Total number of weeks the other parent intends to take(Required)

Indication of start and end dates of ShPL that you (the employee) intend to take. These dates can overlap with your partner’s leave as long as the total 52 week period is not extended. Any SPL not taken in that period will be lost. Please also indicate if you anticipate adding any annual leave and/or parental leave to indicate periods of ShPL.(Required)

This indication is non-binding. You must submit a formal leave of notice (Booking notice Form) for each period of SPL you wish to be binding.

Section D: Shared Parental Pay Details

Please check eligibility for Statutory Shared parental Pay (ShPP) requirements in the Shared Parental Leave Policy.

This section of the form is intended for you to indicate how you and the other parent (if eligible) would like to claim the remaining weeks of pay, once some of the 39 weeks of maternity or adoption pay have been taken and the curtailed.

For example, if the mother takes 10 weeks of maternity leave and pay, there will be 29 weeks remaining to share between eligible parents.

This is an indication at this stage and does not become binding unless you intend it to be, in which case you should also submit a the next Form – Booking Notice (Notice to Take Leave).

Total number of week ShPP available(Required)

Total number of weeks ShPP you (the employee) intends to claim(Required)

Total number of weeks ShPP the other parent intends to claim(Required)

Indication of the start and end dates of your (the employee) ShPP periods(Required)

Section E: Employee Declaration

Employees are reminded that a failure to disclose any changes to their circumstances during the period of shared parental leave may be dealt with as matter of dishonesty and fraud which will be dealt with under the disciplinary process.

I confirm that I have read the Shared Parental Leave Policy and believe that I am entitled to Shared Parental Leave and/or pay. I confirm that:-

• I am the mother, father or main adopter or the partner of the mother, father or main adopter of a child due to be born or adopted on or after 5th April 2015.

• I have (and share) the responsibility for the care of the child and intend to take ShPL in order to care for the child.

• I have at least 26 weeks continuous service of the 15th week before the expected week of childbirth (or the week in which the main adopter was notified of having been matched for adoption with the child) – known as the ‘relevant week’.

• I intend to be in continuous employment until the week before the ShPL is taken.

• (If I am claiming ShPP) I have average weekly earnings equal to or above the lower earnings limit for NI contributions (£112 for 2015/16) over the eight week period ending with the relevant week.

• I agree to inform my line manager (the Trust) immediately if I cease to meet the eligibility requirements for ShPL or ShPP

• I understand that I may be required to produce a copy of the birth certificate/adoption documents and the name, address and contact details of the other parent’s employer.

• The information submitted above is correct.

Signature(Required)

If you are the mother/main adopter you agree you submitted a curtailment of maternity/adoption leave notice by completing Section B

Date(Required)

Section F: Declaration of Other Parent/Partner

You may complete the details of the other parent on their behalf below, you must declare that you have consulted the other parent and the information you have provided is correct.

Name(Required)

National Insurance Number(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer's Name(Required)

Employer's Phone Number(Required)

Employment Details(Required)

Please indicate if you are an office holder or self-employed and the nature of the employment.

Employer’s Address(Required)

Please indicate if you are an office holder or self-employed and the nature of the employment.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Confirmation from Other Parent(Required)

Please upload an email from the other parent confirming that the information you have provided on this form is correct, alternatively you may upload a manual signature (scanned image/ PDF accepted)

Max. file size: 20 MB.

Declaration(Required)

I confirm that I meet the following conditions:

• I have at least 26 weeks’ employment (employed or self-employed) out of 66 weeks prior to the relevant week (see definition in Section E).

• I have average weekly earnings of at least £30 during at least 13 of the 66 weeks prior to the relevant week.

• I confirm I am the father or mother of the child or partner, civil partner or spouse of the mother of the child.

• I agree to inform your employee immediately if I cease to meet the two conditions above.

• I consent to your employee taking ShPL and ShPP as set out in Sections C and D above.

• I consent to providing details of my employer and for them to be contacted to confirm dates and eligibility.

If you are the mother/main adopter:

• I confirm I am entitled to statutory maternity leave, statutory maternity pay or maternity allowance.

• I confirm that at the time of the birth or placement of the child I will share responsibility for the care of the child with your employee.

• I have curtailed my maternity leave and pay/adoption leave and pay/maternity allowance or will have done so by the time your employee commences ShPL.

• I consent to you processing the information contained in this declaration.

Please sign your name below:

Date Signed(Required)

Form 2: Notice to Take or Vary a Period of Shared Parental Leave - Booking Notice (maximum of 3 notices)

Please complete and return this form to your line manager if you wish to request a period of Shared Parental Leave/Shared Parental Pay, or to vary a previously approved period.

You must have previously completed the above sections of the Shared Parental Leave Form in full – ‘The Notice of Entitlement and Intention to Take Shared Parental Leave’ and a Curtailment Notice must have been issued (included in the form details above if the employee is the mother/main adopter). You must give at least eight weeks’ notice of the start of the leave.

There is a maximum of 3 notices that an employee can give.

Please ensure when you complete this form that there have been no changes to your eligibility as defined in the Shared Parental Leave Policy. Both parents are required to sign the declaration at the end of this form.

Your line manager will receive a copy of this form via email and should respond with their approval to the BSO Pay and Conditions team.

If this is not required, please continue to the end of this form and submit your application.

Section A

Name of Employee

Staff Number of Employee

Name of Other Parent

Request to take Shared Parental Leave

Start Date

End Date

Number of weeks SP Leave

Start Date

End Date

Number of Weeks SP Leave

Start Date

End Date

Number of weeks SP Leave

Request to take Shared Parental Pay (if applicable)

Start Date

End Date

Number of weeks SP Leave

Start Date

End Date

Number of weeks SP Leave

Start Date

End Date

Number of weeks SP Leave

Section B: Request to Vary or Cancel Previously Requested Leave

Please note that requests to vary or cancel leave must be made at least eight weeks prior to the date the period of leave varied or cancelled by the notice is due to commence. The new dates must also provide at least 8 weeks’ notice of commencement.

Original ShPL Dates to be Varied

Start Date

End Date

Number of weeks SP Leave

Original ShPL Dates to be Varied

Start Date

End Date

Number of weeks SP Leave

Original ShPL Dates to be Varied

Start Date

End Date

Number of weeks SP Leave

New ShPL Dates

Start Date

End Date

Number of weeks SP Leave

Start Date

End Date

Number of weeks SP Leave

Start Date

End Date

Number of weeks SP Leave

New ShPP Details (if applicable)

Number of weeks ShPP you have claimed/ intent to take

Number of Weeks ShPP the other parent has claimed/ intends to claim

Indication of start and end dates of your ShPP periods

Employee Signature

Please enter your name below as your signature to sign this document

Date Signed

Today

BSO HR Family Leave Application

Your Personal Information

Work Details

Leave Application

Maternity Leave

Pay Options

Paternity Leave

Adoption Leave

Section A

Section B

Section C

Payment Options

Shared Parental Leave Application

Section A

Section B: Employee Notice of Curtailment of Maternity/Adoption Leave

Section C : Shared Parental Leave Details - Notice of Entitlement

Section D: Shared Parental Pay Details

Section E: Employee Declaration

Section F: Declaration of Other Parent/Partner

Form 2: Notice to Take or Vary a Period of Shared Parental Leave - Booking Notice (maximum of 3 notices)

Section A

Request to take Shared Parental Leave

Request to take Shared Parental Pay (if applicable)

Section B: Request to Vary or Cancel Previously Requested Leave

New ShPL Dates

New ShPP Details (if applicable)

Also in this Section

Also in this Section