The HR 112 form serves as a crucial document for employees seeking financial aid in the wake of injuries sustained while on duty. Embedded in the operational framework of the Local Government (Superannuation) (Consolidation) Scheme 1998, this Injury Grant Application Form outlines a structured approach for requesting an injury grant under Article 49/109. It meticulously details the process from the provision of personal details by the employee in Part 1, through the elaboration of accident specifics by the Line Manager in Part 2, to the concluding recommendations made by senior management and the Assistant Director of Human Resource in Part 3. The form mandates the use of block capitals for clarity, alongside checkboxes for ease of completion. It also includes provisions for documenting accident details, investigations, and witness accounts, ensuring a comprehensive record of the event and its aftermath. Noteworthy is the stipulation that any duration for which the injury grant is received will not count towards pension benefit service, underscoring the form’s specificity in addressing immediate financial aid without impacting long-term retirement benefits.
| Question | Answer |
|---|---|
| Form Name | Form Hr 112 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | HR_112_Injury_G rant_Applicatio n_Form injury grant hr112 form |
Injury Grant
Application Form – HR 112
This form is used to apply for a the payment of Injury Grant under Article 49/109 of the Local
Government (Superannuation) (Consolidation) Scheme 1998 in respect of an injury sustained while
performing official duties. Please complete form in Block Capitals/Tick appropriate boxes
Part 1.
Section 1 Personal Details (To be completed by the employee)
Name
PPS No
Personnel No
Grade/Occupation
Service
Address for HSE correspondence
Tel No:
Mobile No:
I understand that should my application be successful, that any period for which I am in receipt of an injury grant will not be included as service for pension benefit purposes.
Signature
Date
Section 2 - Accident Details (To be completed by the Line Manager)
Date of accident
Time of Accident (24 HR Clock)
Place where accident happened?
Details of Accident:
HR 112_V2 Apr 2010 |
Page 1 of 3 |
Revised 01/04/2010 |
What was the employee doing at the time of the Accident?
Nature of Injuries: (Attach a copy of medical certificate or death certificate in the case of a fatality)
Was the employee authorised to be at the place of the accident for the purpose of his/her work?
Yes
No
Date accident first reported to HSE?
To who was the accident reported?
Was an investigation of the accident carried out:
By whom was the accident investigated (attach copies of Incident Report Form, Occupational Health and other relevant reports, witnesses statements, etc)
Yes
No
Section 3 – Witnesses Details (To be completed by Line Manager)
Name:
Address
Tel No:
Name:
Address
Tel No:
Name:
Address
Tel No:
Grade
Mobile No:
Grade
Mobile No:
Grade
Mobile No:
Line Manager Name (print)
Job Title
Contact Tel. No:
Signature:
Date
HR 112_V2 Apr 2010 |
Page 2 of 3 |
Revised 01/04/2010 |
Part 2 To be completed by Senior Manager/General Manager
Under the terms of Article 49/109 of the Local Government (Superannuation) (Consolidation) Scheme 1998
I recommend that the payment of the injury grant is granted in this case
I refuse this application
Comments: (if application is refused, state reason)
Senior Manager Name:
Job Title
Signature
Date
Part 3 To be completed by Assistant Director of Human Resource
Under the terms of Article 49/109 of the Local Government (Superannuation) (Consolidation) Scheme 1998 be invoked in this case to provide for the payment of Injury Grant
I recommend this application
I refuse this application
Comments: (if application is refused, state reason)
Name:
Signature:
Assistant Director of HR
Date
HR 112_V2 Apr 2010 |
Page 3 of 3 |
Revised 01/04/2010 |