Civil Service Form No.

6
Revised 2020
ANNEX A
Republic of the Philippines
Stamp of Date of Receipt
Department of Education
Division of Agusan del Sur
Government Center, Patin-ay, Prosperidad, Agusan del Sur

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
DEPARTMENT OF EDUCATION BUDUMO, RYAN TAGALOG

3. DATE OF FILING 01/24/2023 4. POSITION TEACHER III 5. SALARY 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)
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) In case of Special Leave Benefits for Women:
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005) (Specify Illness)
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) In case of Study Leave:
Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Completion of Master's Degree
Adoption Leave (R.A. No. 8552) BAR/Board Examination Review
Other purpose:
Others: Monetization of Leave Credits
Terminal Leave

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

Not Requested
INCLUSIVE DATES Requested
JANUARY 23, 2023
(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION
As of For approval
Vacation Leave Sick Leave For disapproval due to
Total Earned
Less this application
Balance

DANDY V. ANINO LUIS P. RIQUE

Administrative Officer V (Authorized Officer)

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

days with pay
days without pay
others (Specify)

HECTOR DN. MACALALAG PhD.

Schools Division Superintendent
 INSTRUCTIONS AND REQUIREMENTS
Application for any type of leave shall be made on this Form and to be TPO or PPO has been filed with the said office shall be sufficient
accomplished at least in duplicate with documentary requirements, as to support the application for the ten-day leave; or
follows: d. In the absence of the BPO/TPO/PPO or the certification, a police
report specifying the details of the occurrence of violence on the
1. Vacation leave* victim and a medical certificate may be considered, at the
It shall be filed five (5) days in advance, whenever possible, of the discretion of the immediate supervisor of the woman employee
effective date of such leave. Vacation leave within in the Philippines concerned.
or abroad shall be indicated in the form for purposes of securing travel
authority and completing clearance from money and work 10. Rehabilitation leave* – up to 6 months
accountabilities.
 Application shall be made within one (1) week from the time of the
accident except when a longer period is warranted.
2. Mandatory/Forced leave
 Letter request supported by relevant reports such as the police
Annual five-day vacation leave shall be forfeited if not taken during the
report, if any,
year. In case the scheduled leave has been cancelled in the exigency
 Medical certificate on the nature of the injuries, the course of
of the service by the head of agency, it shall no longer be deducted from
treatment involved, and the need to undergo rest, recuperation, and
the accumulated vacation leave. Availment of one (1) day or more
rehabilitation, as the case may be.
Vacation Leave (VL) shall be considered for complying the
mandatory/forced leave subject to the conditions under Section 25, Rule  Written concurrence of a government physician should be
XVI of the Omnibus Rules Implementing E.O. No. 292. obtained relative to the recommendation for rehabilitation if the
attending physician is a private practitioner, particularly on the
3. Sick leave* duration of the period of rehabilitation.
 It shall be filed immediately upon employee's return from such leave.
11. Special leave benefits for women* – up to 2 months
 If filed in advance or exceeding five (5) days, application shall be
 The application may be filed in advance, that is, at least five (5) days
accompanied by a medical certificate. In case medical consultation
prior to the scheduled date of the gynecological surgery that will
was not availed of, an affidavit should be executed by an applicant.
be undergone by the employee. In case of emergency, the
application for special leave shall be filed immediately upon
4. Maternity leave* – 105 days
employee’s return but during confinement the agency shall be
 Proof of pregnancy e.g. ultrasound, doctor’s certificate on the
notified of said surgery.
expected date of delivery
 The application shall be accompanied by a medical certificate
 Accomplished Notice of Allocation of Maternity Leave Credits (CS
filled out by the proper medical authorities, e.g. the attending
Form No. 6a), if needed
surgeon accompanied by a clinical summary reflecting the
 Seconded female employees shall enjoy maternity leave with full pay
gynecological disorder which shall be addressed or was
in the recipient agency.
addressed by the said surgery; the histopathological report; the
operative technique used for the surgery; the duration of the
5. Paternity leave – 7 days
surgery including the peri- operative period (period of
Proof of child’s delivery e.g. birth certificate, medical certificate and
confinement around surgery); as well as the employees estimated
marriage contract
period of recuperation for the same.
6. Special Privilege leave – 3 days
12. Special Emergency (Calamity) leave – up to 5 days
It shall be filed/approved for at least one (1) week prior to availment,
 The special emergency leave can be applied for a maximum of five
except on emergency cases. Special privilege leave within the
(5) straight working days or staggered basis within thirty (30) days
Philippines or abroad shall be indicated in the form for purposes of
from the actual occurrence of the natural calamity/disaster. Said
securing travel authority and completing clearance from money and work
privilege shall be enjoyed once a year, not in every instance of
accountabilities.
calamity or disaster.
 The head of office shall take full responsibility for the grant of special
7. Solo Parent leave – 7 days
emergency leave and verification of the employee’s eligibility to be
It shall be filed in advance or whenever possible five (5) days before
granted thereof. Said verification shall include: validation of place of
going on such leave with updated Solo Parent Identification Card.
residence based on latest available records of the affected
employee; verification that the place of residence is covered in the
8. Study leave* – up to 6 months
declaration of calamity area by the proper government agency;
 Shall meet the agency’s internal requirements, if any; and such other proofs as may be necessary.
 Contract between the agency head or authorized representative
and the employee concerned. 13. Monetization of leave credits
Application for monetization of fifty percent (50%) or more of the
9. VAWC leave – 10 days accumulated leave credits shall be accompanied by letter request to
 It shall be filed in advance or immediately upon the woman the head of the agency stating the valid and justifiable reasons.
employee’s return from such leave.
 It shall be accompanied by any of the following supporting documents: 14. Terminal leave*
a. Barangay Protection Order (BPO) obtained from the barangay; Proof of employee’s resignation or retirement or separation from the
b. Temporary/Permanent Protection Order (TPO/PPO) obtained from service.
the court;
c. If the protection order is not yet issued by the barangay or the court, 15. Adoption Leave
a certification issued by the Punong Barangay/Kagawad or  Application for adoption leave shall be filed with an authenticated
Prosecutor or the Clerk of Court that the application for the BPO, copy of the Pre-Adoptive Placement Authority issued by the
Department of Social Welfare and Development (DSWD).

* 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).