Employee Set up form HR 101 This form is to be completed for all new entrants and forwarded to Personnel Administration. Please complete in block capitals & place a tick in the appropriate boxes Hire Re-hire Internal HSE Payroll Transfer Permanent Temporary Personnel Number Start Sections 1-9 should be completed by Employee. 1. Personal Information Title Mr Mrs Ms Miss Dr Sr. Rev. Fr. Prof. Surname Known as First Name Initials Street Address Town/City County Post Code Country Phone Mobile Phone Email address for online payslip purposes Maiden Name Nationality Gender Male Female of Birth Marital Status Single Married Civil Partnership Widowed Divorced Separated Co-Habiting Relevant certificate/s attached 2. Next of Kin (Emergency Contact Details) Surname PPS Number First Name Relationship to you Street Address Town/City County Post code Country Contact Phone Mobile Phone 3. Employment History Are you Currently employed by HSE / Public Service If currently employed by HSE please provide details of your personnel number and pay group/payroll area. Personnel Number Pay group / payroll area Were you previously employed by HSE / Health Board / Voluntary Hospital / National Hospital/ Public Service Employer? If please go to section 4 If previously employed by HSE / Health Board / Voluntary Hospital / National Hospital please provide the following details. (te: if you have had multiple assignments with these employers please provide details of your latest employment) Name of employer Grade Last Day of service Personnel Number HR 101_V10 June 2016 Page 1 of 6 Revised 15/06/2016
Are you in receipt of a pension under the Local Government Superannuation Scheme or HSE Superannuation Scheme? If please provide information requested below Name of Authority/ Employer Start of Payment 4. Bank Details Bank Name Bank Address Bank Sort Code Account Bank Identifier Code (BIC) International Bank Account (IBAN) Payee Name 5. Professional te: only applies to Medical & Dental, Health & Social Care Professionals & Nursing. If this section does not apply to you go to section 6. If you have multiple registrations please complete Appendix 1. of issue Expiry Application Status (Medical Council) 6. PRSI Details Trainee Specialist Internship Specialist General Supervised Visiting EEA Practitioners PRSI Class: Are you a Full Medical Card Holder? Are you a GP Visit Card Holder? Are you a widow / widower? Are you a lone Parent? 7. Qualification Details te: Copy of Certificates to be attached Name of Qualification from te: if you have answered yes to any of these questions please attach supporting documentation from Dept of Social Protection (Social Welfare) or HSE Proficiency/ Grade awarded Qualification Code (if applicable) Official use only Validated Please ( ) tick one HR 101_V10 June 2016 Page 2 of 6 Revised 15/06/2016
8. Irish Language Proficiency Oral Irish Validated Native Intermediate Fluent Beginner/ vice ne Unknown / Untested Written Irish Advanced Intermediate Basic ne Unknown / Untested 9. Employee Declaration I declare that the above information is accurate and correct on the date below. I undertake to notify my employer of any changes to this information by completing and submitting the appropriate form. Sections 10-18 should be completed by Line Manager/ Human Resources 10. Appointment Details Employed as (Grade) D Position Name Position Number Cost Centre Care Group Personnel Area Work Address Employee Group Permanent Officer Temporary n Officer Employee Sub Group Wholetime Part-time Casual Reason for Appointment or Action Name of Replaced Employee: Org Unit Name: 11. Contract [please attach signed contract] Contract Type Fees/ Sessions Flexible Job share Working Fill Existing Vacancy Maternity Leave Relief Locum Relief Fill New Vacancy Sick Leave Relief National Transfer Special Project Annual Leave Relief Local Transfer Student Training Post Career Break Cover Redeployment Community Employment Scheme Urgent Service Needs SJH Hire Pension Purposes Only (Special) Student Summer Scheme Locum On-Call Relief Agency Subsumed into HSE Agency Staff Converted to EE Replaced Employee Personnel. Indefinite Duration Indefinite Duration Std T&C s Org Unit Number Fixed Term Fixed Term Std T&C s Specified Purpose Specified Purpose Std T&C s Indefinite Duration Std T&C s 06/2014 Fixed Term Std T&C s 06/2014 Specified Purpose Std T&C s 06/2014 Consultant Contract type A B B* C Expiry of Temporary Contract (if applicable) 1st probationary Review date 2 nd probationary Review date 12. Allowances - Please ensure that supporting documentation is attached 1 Allowance Amount / Unit Probation period to be served Wage Type / Pay code Official use only HR 101_V10 June 2016 Page 3 of 6 Revised 15/06/2016
2 13. Work Pattern Standard Full Time hours for this grade Contract Hours (use decimals) Work Schedule rule details (SAP Phase II Sites Only) Working Week Mon Fri 5/5 Mon Sun 5 / 7 te: If an employee works a Monday to Friday roster they are classed as 5/5. These employees will never be paid Saturday allowance, Sunday premiums or Public Holiday premiums. Alternatively if an employee may work on a Saturday or Sunday they are classed as 5/7, this will allow them to be paid the relevant allowances and premiums WORK SCHEDULE RULE* *This box must be completed (If employee is casual, enter HRPD) 14. Pay Details Work Location Start week of Rotational Roster Annual Salary Level (Point of Scale) Grade Code Pay Scale Type Next Increment due Pay Scale Area Payroll Area/Group Pay slip distribution Internal External Email Payroll Frequency Weekly Fortnightly 4 weekly Monthly 15. Pension Details Superannuation classification to be completed in all cases n New Entrant New Entrant SPSPS Is this employee eligible for membership of a superannuation scheme If yes please indicated the relevant superannuation scheme PRSI Class A Officer PRSI Class D n Officer 1956 Scheme 120 120 200 1977 [Revision Scheme ] Main Scheme 160 140 220 Spouses & Children s 320 320 420 Widows & Orphans N/A 300 400 Officer / n Officer HSE Employee Superannuation Scheme Main Scheme 165 Spouses & Children s 325 Public Service Pensions [Single Scheme] 170 HR 101_V10 June 2016 Page 4 of 6 Revised 15/06/2016
16. Service year date (for annual leave purposes) te: Certain grades are entitled to incremental increases to the annual leave entitlement based on length of service in the grade. Please complete the following section so that the correct entitlement may be established. Is the employee entitled to incremental increases to annual leave, based on length of service? If Go To Section 18 Nursing Grades only If yes please enter the number of years, months and days of previous service. te: Please include all previous service in publicly funded health services in Ireland and relevant nursing experience abroad Other Grades If yes please enter the number of years, months and days of relevant service at this grade te: Please include service if the employee was acting up continuously in the same grade immediately prior to start date 17. Line Manager Declaration te: Please ensure P45 / Certificate of Tax Cut Off / PRD45 are forwarded to the appropriate payroll department Fit Slip Attached Years Months Days Years Months Days I declare that the above information is accurate and correct. I confirm that the above employee commenced employment on the date stated above and approve set up on the appropriate payroll system. Name (Print) Contact Tel Grade Decision Number (if applicable) E-Mail Address 18. Delegated Officer approval Regional HR and/or Service Director Name (Print) Tel Decision 19. Area Employment Monitoring Group Approval Number 20. To be completed by Human Resources Personnel Administration System Updated by Comments HR 101_V10 June 2016 Page 5 of 6 Revised 15/06/2016
21. Payroll Section Location Code Name (Print) Tel 22. Payroll Interface (phase 1 Only) Wage Type Entered Payroll Area Change Details Main Pension Scheme PAC Completed Employment Signal W&O/Spouses Scheme Signed 23. Circulation List 1 5 2 6 3 7 4 8 Appendix 1 Professional additional information for multiple registrations te only applies to Dentists, Doctors, Nurses, Ophthalmologists, or Pharmacists of issue Expiry of issue Expiry of issue Expiry HR 101_V10 June 2016 Page 6 of 6 Revised 15/06/2016