Civil Service Form No.

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

DIVISION OF CAMARINES SUR

San Jose, Pili, Camarines Sur

APPLICATION FOR LEAVE

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

DEPED, PERSONNEL UNIT PATRIARCA MEA MUSCA

3. DATE OF FILING January 24, 2022 4. POSITION Teacher 1 5. SALARY PHP 23,877.00

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

105 DAYS Not Requested

INCLUSIVE DATES Requested

January 24,2022 to May 8, 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 - -

Authorized Officer Authorized Officer

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

days with pay

 days without pay

others (Specify)

Authorized Officer

INSTRUCTIONS AND REQUIREMENTS

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