Civil Service Form No.

6
Revised 2020

Republic of the Philippines

Department of Education
REGION VIII
SCHOOLS DIVISION OF NORTHERN SAMAR

APPLICATION FOR LEAVE

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

DEped- LAOANG NATIONAL HIGH SCHOOL LIPATA MICHAELA JHYZZEL DIOLAS

Administrative Assistant II ₱ 19, 472.16

3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________

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

105 days
________________________________________ Not Requested
INCLUSIVE DATES Requested
________________________________________
(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 ___________________________________________

CARMENCITA L. MARTIRES
___________________________________________
(Authorized Officer) (Authorized Officer)

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

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________

_________________________________
(Authorized Official)
 INSTRUCTIONS AND REQUIREMENTS
Application for any type of leave shall be made on this Form and a. Barangay Protection Order (BPO) obtained from the
to be accomplished at least in duplicate with documentary barangay;
requirements, as follows: b. Temporary/Permanent Protection Order (TPO/PPO)
obtained from the court;
1. Vacation leave* c. If the protection order is not yet issued by the barangay
It shall be filed five (5) days in advance, whenever possible, of or the court, a certification issued by the Punong
the effective date of such leave. Vacation leave within in the Barangay/Kagawad or Prosecutor or the Clerk of Court
Philippines or abroad shall be indicated in the form for that the application for the BPO, TPO or PPO has been
purposes of securing travel authority and completing filed with the said office shall be sufficient to support the
* For leave of absence
clearance from moneyfor thirty
and (30)
workcalendar days or more and terminal leave, application
accountabilities. shall be
application for accompanied by a clearance
the ten-day leave; or from money, property and
work-related accountabilities (pursuant to CSC Memorandum Circular No. 2, s. 1985).
d. In the absence of the BPO/TPO/PPO or the certification,
2. Mandatory/Forced leave a police report specifying the details of the occurrence of
Annual five-day vacation leave shall be forfeited if not taken violence on the victim and a medical certificate may be
during the year. In case the scheduled leave has been considered, at the discretion of the immediate supervisor
cancelled in the exigency of the service by the head of of the woman employee concerned.
agency, it shall no longer be deducted from the accumulated
vacation leave. Availment of one (1) day or more Vacation 10. Rehabilitation leave* – up to 6 months
Leave (VL) shall be considered for complying the  Application shall be made within one (1) week from the
mandatory/forced leave subject to the conditions under time of the accident except when a longer period is
Section 25, Rule XVI of the Omnibus Rules Implementing E.O. warranted.
No. 292.  Letter request supported by relevant reports such as the
police report, if any,
3. Sick leave*  Medical certificate on the nature of the injuries, the course
 It shall be filed immediately upon employee's return from of treatment involved, and the need to undergo rest,
such leave. recuperation, and rehabilitation, as the case may be.
 If filed in advance or exceeding five (5) days, application  Written concurrence of a government physician should be
shall be accompanied by a medical certificate. In case obtained relative to the recommendation for rehabilitation
medical consultation was not availed of, an affidavit should if the attending physician is a private practitioner,
be executed by an applicant. particularly on the duration of the period of rehabilitation.

4. Maternity leave* – 105 days 11. Special leave benefits for women* – up to 2 months
 Proof of pregnancy e.g. ultrasound, doctor’s certificate on  The application may be filed in advance, that is, at least
the expected date of delivery five (5) days prior to the scheduled date of the
 Accomplished Notice of Allocation of Maternity Leave gynecological surgery that will be undergone by the
Credits (CS Form No. 6a), if needed employee. In case of emergency, the application for
 Seconded female employees shall enjoy maternity leave special leave shall be filed immediately upon employee’s
with full pay in the recipient agency. return but during confinement the agency shall be notified
of said surgery.
5. Paternity leave – 7 days  The application shall be accompanied by a medical
Proof of child’s delivery e.g. birth certificate, medical certificate certificate filled out by the proper medical authorities, e.g.
and marriage contract the attending surgeon accompanied by a clinical summary
reflecting the gynecological disorder which shall be
6. Special Privilege leave – 3 days addressed or was addressed by the said surgery; the
It shall be filed/approved for at least one (1) week prior to histopathological report; the operative technique used for
availment, except on emergency cases. Special privilege the surgery; the duration of the surgery including the peri-
leave within the Philippines or abroad shall be indicated in the operative period (period of confinement around surgery);
form for purposes of securing travel authority and completing as well as the employees estimated period of recuperation
clearance from money and work accountabilities. for the same.

7. Solo Parent leave – 7 days 12. Special Emergency (Calamity) leave – up to 5 days
It shall be filed in advance or whenever possible five (5) days  The special emergency leave can be applied for a
before going on such leave with updated Solo Parent maximum of five (5) straight working days or staggered
Identification Card. basis within thirty (30) days from the actual occurrence of
the natural calamity/disaster. Said privilege shall be
8. Study leave* – up to 6 months enjoyed once a year, not in every instance of calamity or
 Shall meet the agency’s internal requirements, if any; disaster.
 Contract between the agency head or authorized  The head of office shall take full responsibility for the grant
representative and the employee concerned. of special emergency leave and verification of the
employee’s eligibility to be granted thereof. Said
9. VAWC leave – 10 days verification shall include: validation of place of residence
 It shall be filed in advance or immediately upon the woman based on latest available records of the affected
employee’s return from such leave. employee; verification that the place of residence is
 It shall be accompanied by any of the following supporting covered in the declaration of calamity area by the proper
documents: government agency; and such other proofs as may be
necessary.

13. Monetization of leave credits