Sick Pay Social Welfare Form Template for Ireland

The Sick Pay Social Welfare Form is a standardized document used in Ireland when employees need to claim statutory sick pay and illness benefits. It was developed following the introduction of the Sick Leave Act 2022, which established statutory sick pay rights for all eligible employees in Ireland. The form must be completed when an employee requires sick leave and wishes to claim associated benefits, containing sections for personal information, employment details, medical certification, and payment information. It serves as an official record of the sick leave claim and facilitates communication between all relevant parties - the employee, employer, medical practitioner, and the Department of Social Protection. The document is designed to comply with both employment law and data protection requirements, ensuring proper handling of sensitive medical information while streamlining the benefits claim process.

1. Personal Details: Employee's full name, PPS number, date of birth, and contact information

2. Employment Information: Employer details, employment start date, work pattern, and PRSI class

3. Absence Details: First day of illness, expected duration, nature of illness (if disclosed), and return to work date if known

4. Payment Details: Bank account information for benefit payment, including IBAN and BIC

5. Medical Certification: Section for healthcare provider to complete, including diagnosis (where appropriate), duration of certified illness, and medical practitioner's details

6. Declaration: Employee declaration confirming truth of information provided and consent for data processing