Civil Service Form No.

6
Revised 2020

Republic of the Philippines

Stamp of Date of Receipt
DEPARTMENT OF EDUCATION
Region IX, Zamboanga Peninsula
Division of Zamboanga del Norte
Liloy III District
OVERVIEW ELEMENTARY SCHOOL

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME: (Last) (First) (Middle)

DEP.ED COLANGGO JUDITH ALOJADO

3. DATE OF FILING 09/23/2022 4. POSITION Teacher- III 5. SALARY PHP 29,798.00

6. DETAILS OF APPLICATION

6.A TYPE OF LEAVE TO BE AVAILED OF 6.B DETAILS OF LEAVE

Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Vacation/Special Privilege Leave:

Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines

/ Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Abroad (Specify)

Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE and SSS) In case of Sick Leave:
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) In Hospital (Specify Illness)
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing E.O. No. 292) / Out Patient (Specify Illness)
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) In case of Special Leave Benefits for Women:

Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) (Specify Illness)
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) In case of Study Leave:

Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Completion of Master's Degree

Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) BAR/Board Examination Review Other

Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) purpose:

Adoption Leave (R.A. No. 8552) Monetization of Leave Credits

Others: Terminal Leave

6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

1 Day Not Requested

INCLUSIVE DATES Requested

September 22,2022
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION

As of

Vacation Leave Sick Leave For approval

Total Earned For disapproval due to

Less this application
Balance

MARYLYNNE B. BAYRON LEOMARDE A. FERNANDEZ

Authorized Officer Authorized Officer
7.C APPROVED FOR: 7. D DISAPPROVED DUE TO:

days with pay

days without pay
others (Specify)

VIRGILIO P. BATAN JR., CESO VI

Authorized Officer

INSTRUCTIONS AND REQUIREMENTS

Application for any type of leave shall be made on this Form and to be accomplished d. In the absence of the BPO/TPO/PPO or the certification, a police report
at least in duplicate with documentary requirements, as follows: specifying the details of the occurrence of violence on the victim and a medical
certificate may be considered, at the discretion of the immediate supervisor of
1. Vacation leave* the woman employee concerned.
It shall be filed five (5) days in advance, whenever possible, of the effective date of
such leave. Vacation leave within in the Philippines or abroad shall be indicated in 10. Rehabilitation leave* – up to 6 months
the form for purposes of securing travel authority and completing clearance from • Application shall be made within one (1) week from the time of the accident
money and work accountabilities. except when a longer period is warranted.
• Letter request supported by relevant reports such as the police report, if any,
2. Mandatory/Forced leave • Medical certificate on the nature of the injuries, the course of treatment
Annual five-day vacation leave shall be forfeited if not taken during the year. In involved, and the need to undergo rest, recuperation, and rehabilitation, as the
case the scheduled leave has been cancelled in the exigency of the service by the case may be.
head of agency, it shall no longer be deducted from the accumulated vacation leave. • Written concurrence of a government physician should be obtained relative
Availment of one (1) day or more Vacation Leave (VL) shall be considered for to the recommendation for rehabilitation if the attending physician is a private
complying the mandatory/forced leave subject to the conditions under Section 25, practitioner, particularly on the duration of the period of rehabilitation.
Rule XVI of the Omnibus Rules Implementing E.O. No. 292.
11. Special leave benefits for women* – up to 2 months
3. Sick leave* • The application may be filed in advance, that is, at least five (5) days prior to
• It shall be filed immediately upon employee's return from such leave. the scheduled date of the gynecological surgery that will be undergone by the
• If filed in advance or exceeding five (5) days, application shall be accompanied by employee. In case of emergency, the application for special leave shall be
a medical certificate. In case medical consultation was not availed of, an affidavit filed immediately upon employee’s return but during confinement the agency
should be executed by an applicant. shall be notified of said surgery.
• The application shall be accompanied by a medical certificate filled out by the
4. Maternity leave* – 105 days proper medical authorities, e.g. the attending surgeon accompanied by a
• Proof of pregnancy e.g. ultrasound, doctor’s certificate on the expected date of clinical summary reflecting the gynecological disorder which shall be
delivery addressed or was addressed by the said surgery; the histopathological report;
• Accomplished Notice of Allocation of Maternity Leave Credits (CS Form No. 6a), if the operative technique used for the surgery; the duration of the surgery
needed including the perioperative period (period of confinement around surgery); as
• Seconded female employees shall enjoy maternity leave with full pay in the well as the employees estimated period of recuperation for the same.
recipient agency.
12. Special Emergency (Calamity) leave – up to 5 days
5. Paternity leave – 7 days • The special emergency leave can be applied for a maximum of five (5)
Proof of child’s delivery e.g. birth certificate, medical certificate and marriage straight working days or staggered basis within thirty (30) days from the actual
contract occurrence of the natural calamity/disaster. Said privilege shall be enjoyed
once a year, not in every instance of calamity or disaster.
6. Special Privilege leave – 3 days • The head of office shall take full responsibility for the grant of special
It shall be filed/approved for at least one (1) week prior to availment, except on emergency leave and verification of the employee’s eligibility to be granted
emergency cases. Special privilege leave within the Philippines or abroad shall be thereof. Said verification shall include: validation of place of residence based
indicated in the form for purposes of securing travel authority and completing on latest available records of the affected employee; verification that the place
clearance from money and work accountabilities. of residence is covered in the declaration of calamity area by the proper
government agency; and such other proofs as may be necessary.
7. Solo Parent leave – 7 days
It shall be filed in advance or whenever possible five (5) days before going on such 13. Monetization of leave credits
leave with updated Solo Parent Identification Card. Application for monetization of fifty percent (50%) or more of the accumulated
leave credits shall be accompanied by letter request to the head of the agency
8. Study leave* – up to 6 months stating the valid and justifiable reasons.
• Shall meet the agency’s internal requirements, if any;
• Contract between the agency head or authorized representative and the employee 14. Terminal leave*
concerned. Proof of employee’s resignation or retirement or separation from the service.

9. VAWC leave – 10 days 15. Adoption Leave

• It shall be filed in advance or immediately upon the woman employee’s return from • Application for adoption leave shall be filed with an authenticated copy of the
such leave. Pre-Adoptive Placement Authority issued by the Department of Social Welfare
• It shall be accompanied by any of the following supporting documents: and Development (DSWD).
a. Barangay Protection Order (BPO) obtained from the barangay;
b. Temporary/Permanent Protection Order (TPO/PPO) obtained from the court;
c. If the protection order is not yet issued by the barangay or the court, a certification
issued by the Punong Barangay/Kagawad or
Prosecutor or the Clerk of Court that the application for the BPO, TPO or PPO has
been filed with the said office shall be sufficient to support the application for the
ten-day leave; or

* For leave of absence for thirty (30) calendar days or more and terminal leave, application shall be accompanied by a clearance from money, property and
work-related accountabilities (pursuant to CSC Memorandum Circular No. 2, s. 1985).