Civil Service Form No.

6 ANNEX A
Revised 2020
Republic of the Philippines
Stamp of Date of Receipt
Department of Education

SCHOOLS DIVISION OF GAPAN CITY

San Vicente, Gapan City

APPLICATION FOR LEAVE

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

BUNGO ES DOMINGO MARK JASON SICAT

3. DATE OF FILING October 6, 2023 . POSITION ADMINISTRATIVE OFFICER II 5. SALARY PHP 27,284.00

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

25 DAYS Not Requested

INCLUSIVE DATES x Requested

(Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

7.A CERTIFICATION OF LEAVE CREDITS 7.B RECOMMENDATION

As of

Vacation Leave Sick Leave x For approval

Total Earned
For disapproval due to
Less this application
Balance - - FANNY ROSE V. AVILES
School Principal I

GIAN CARLO P. DOMINGO

Administrative Officer IV

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

days with pay
days without pay
others (Specify)

JOSIE C. PALIOC, CESE

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