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
Personnel Number
D
Start Date
Temporary
D
M
M
Y
Y
Y
Y
Sections 1-9 should be completed by Employee.
1. Personal Information
Title
Mr
Mrs
Ms
Miss
Dr
Sr.
Surname
First Name
Known as
Initials
Rev.
Fr.
Prof.
Street Address
Town/City
County
Post Code
Phone No
Country
Mobile Phone No
Email address for payslip purposes
Maiden Name
Nationality
D
Gender
Male
Marital Status
Female
Single 
Relevant certificate/s attached Yes
D
M
M
Y
Y
Y
Y
Date of Birth
Married 
Civil Partnership 
Widowed 
Divorced 
Separated 
Co-Habiting 
PPS
Number
No
2. Next of Kin (Emergency Contact Details)
Surname
First Name
Relationship to you
Street Address
Town/City
County
Post code
Contact Phone No
Country
Mobile Phone No
3. Employment History
Are you Currently employed by HSE / Public Service
Yes
No
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 No please go to section 4
Yes
No
If previously employed by HSE / Health Board / Voluntary Hospital / National Hospital please provide the following details. (Note: if you have had
multiple assignments with these employers please provide details of your latest employment)
D
Name of employer
Grade
D
M
M
Y
Last Day of service
Personnel Number
HR 101_V5 Oct 2013
Page 1 of 6
Revised 23/10/2013
Y
Y
Y
If Faxing please ensure the employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No.__________________________________
Are you in receipt of a pension under the Local Government Superannuation Scheme or HSE Superannuation Scheme?
Yes
No
If Yes please provide information requested below
D
Name of Authority/ Employer
D
M
M
Y
Y
Y
Y
Start Date of Payment
4. Bank Details
Bank Name
Bank Address
Bank Sort Code
Account No
Bank Identifier Code (BIC)
International Bank
Account No (IBAN)
Payee Name
5. Professional Registration
Note: 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.
Name on
Registration
Issued By
D
D
M
M
Y
Y
Y
Y
Date of issue
D
D
M
M
Y
Y
Y
Y
Expiry Date
Professional Registration / Membership Number
6. PRSI Details
PRSI Class:
Are you a Full Medical Card Holder?
Yes
No
Are you a GP Visit Card Holder?
Yes
No
Note: if you have answered yes to any of these questions
Are you a widow / widower?
Yes
No
please attach supporting documentation from Dept of Social
Protection (Social Welfare) or HSE
Are you a lone Parent?
Yes
No
7. Qualification Details
Note: Copy of Certificates to be attached
Official use only
Name of Qualification
D
D
D
D
D
HR 101_V5 Oct 2013
Proficiency/
Grade awarded
Date from
D
D
D
D
D
M
M
M
M
M
M
M
M
M
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Qualification Code
(if applicable)
Validated
Please () tick one
Y
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Y
Y
Y
Y
Page 2 of 6
Revised 25/10/2013
If Faxing please ensure the employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No.__________________________________
8. Irish Language Proficiency
Oral Irish
Native
Validated
Intermediate
Fluent
Beginner/ Novice
None
Unknown / Untested
Yes
No
Yes
No
Written Irish
Advanced
Intermediate
Basic
None
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.
D
Signature
D
M
M
Y
Y
Y
Y
Date
Sections 10 - 18 should be completed by Line Manager/ Human Resources
10. Appointment Details
Employed as (Grade)
D
Position
Name
M
M
Cost
Centre
Y
Y
Work
Address
Y
Y
Position Number
Care Group
Personnel Area
Permanent
Temporary
Officer
Non Officer
Wholetime
Part-time
Employee Group
Employee Sub Group
Casual
Fill Existing Vacancy 
Fill New Vacancy 
Special Project 
Student Training Post 
Community Employment Scheme 
Reason for Appointment or
Action
Student Summer Scheme 
Name of Replaced Employee:
Fees/ Sessions
Maternity Leave Relief 
Sick Leave Relief 
Annual Leave Relief 
Career Break Cover 
Urgent Service Needs
(Special)
Locum On-Call Relief 
Replaced Employee
Personnel No.
Org Unit Name:
Flexible
Working
Job share
Locum Relief 
National Transfer 
Local Transfer 
Redeployment 
SJH Hire Pension Purposes Only 
Agency Subsumed into HSE 
Org Unit Number
11. Contract – [please attach signed contract]
Indefinite
Duration
Contract Type
Indefinite Duration
Std T&C’s
Fixed Term
A
Consultant Contract type
Expiry Date of Temporary
Contract (if applicable)
1st probationary
Review date
Fixed Term
Std T&C’s
D
D
D
M
M
Y
Y
Y
Specified
Purpose
B
Specified Purpose
Std T&C’s
B*
C
Y
Probation period to be served
D
M
M
Y
Y
Y
Y
2nd probationary
Review date
D
D
M
Yes
M
No
Y
Y
Y
12. Allowances - Please ensure that supporting documentation is attached
Allowance
Amount / Unit
Wage Type / Pay code
Official use only
1
2
HR 101_V5 Oct 2013
Page 3 of 6
Revised 25/10/2013
Y
If Faxing please ensure the employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No.__________________________________
13. Work Pattern
Standard Full Time hours for this grade
Contract Hours (use decimals)
Work Schedule rule details (SAP Phase II Sites Only)
Mon – Fri 5/5
Working Week
Mon – Sun 5 / 7
Note:
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*
Start week of Rotational Roster
* (If employee is casual, enter HRPD)
14. Pay Details
Work Location
Annual Salary €
Level (Point of Scale)
D
D
M
M
Y
Y
Y
Grade Code
Y
Next Increment due
Payroll Area/Group No
Pay slip distribution
Payroll Frequency
Internal
Weekly
External
Email
Fortnightly
4 weekly
Monthly
15. Pension Details
Superannuation classification to be completed in all cases
New Entrant
Is this employee eligible for membership of a superannuation scheme
If yes please indicated the relevant
superannuation scheme
Yes
Non New Entrant
No
Officer
Non Officer
PRSI Class A
PRSI Class D
1956 Scheme
120
120
200
1977 [Revision Scheme ] – Main Scheme
160
140
220
Spouses’ & Children’s
320
320
420
300
400
Widows’ & Orphans’
N/A
Officer / Non Officer
HSE Employee Superannuation Scheme – Main Scheme
165
Spouses’ & Children’s
325
Public Service Pensions [Single Scheme]
170
HR 101_V5 Oct 2013
Page 4 of 6
Revised 25/10/2013
If Faxing please ensure the employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No.__________________________________
17. Service year date (for annual leave purposes)
Note: 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?
Yes
No
If No Go To Section 18
Nursing Grades only
If yes please enter the number of years, months and days of previous service.
Note: Please include all previous service in publicly funded health services in Ireland and relevant
nursing experience abroad
Years
Months
Days
Years
Months
Days
Other Grades
If yes please enter the number of years, months and days of relevant service at this grade Note:
Please include service if the employee was acting up continuously in the same grade immediately
prior to start date
18. Line Manager Declaration
Note: Please ensure P45 / Certificate of Tax Cut Off / PRD45 are forwarded to the appropriate payroll department
Fit Slip Attached
Yes
No
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.
D
D
M
Signature
Date
Name (Print)
Grade
Contact Tel No
Decision Number (if applicable)
M
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
E-Mail Address
19. Delegated Officer approval
Name (Print)
Signature
Tel No
Date
D
D
M
M
Decision No
20. Area Employment Monitoring Group
D
Approval Number
D
M
M
Date
21. To be completed by Human Resources Personnel Administration
D
System Updated by
D
M
M
Date
Comments
HR 101_V5 Oct 2013
Page 5 of 6
Revised 25/10/2013
If Faxing please ensure the employee’s Name and Personnel Number are included for each page of form
Name ____________________________ Personnel No.__________________________________
22. Payroll Section
Location Code
Name (Print)
Signature
Tel No
Date
D
D
M
M
Y
Y
Y
Y
D
M
M
Y
Y
Y
Y
M
M
Y
Y
Y
Y
23. Payroll Interface (phase 1 Only)
Wage Type Entered
Employment Signal
Payroll Area Change Details
Date
Main Pension Scheme
W&O/Spouses Scheme
PAC Completed
Date
D
D
D
Signed
24. Circulation List
1
5
2
6
3
7
4
8
Appendix 1 Professional Registration additional information for multiple registrations
Note only applies to Dentists, Doctors, Nurses, Ophthalmologists, or Pharmacists
Name on
Registration
Issued By
D
D
M
M
Y
Y
Y
Y
Date of issue
D
D
M
M
Y
Y
Y
Y
Expiry Date
Professional Registration / Membership Number
Name on
Registration
Issued By
D
D
M
M
Y
Y
Y
Y
Date of issue
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Expiry Date
Professional Registration / Membership Number
Name on
Registration
Issued By
D
D
M
M
Y
Y
Y
Y
Date of issue
Expiry Date
Professional Registration / Membership Number
HR 101_V5 Oct 2013
Page 6 of 6
Revised 25/10/2013