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Second Schedule (Section 34) 60130-9
APPLICATION FOR LEAVE
NOTES
1. An amended Leave Form must be clearly marked – either “AMENDED/CANCELLED, ORIGINAL DATES WERE ……………………………….
TO ………………………………………….”
2. Original to: Manager, Salary Service Bureau, P.O.Box CY507, Causeway.
3. For all sick-leave in excess of three consecutive working days (six consecutive working days in other areas; and all sick-leave in the Uniformed Forces;
excluding Prisons Service who have conditions aligned to Public Service), a certificate in the form shown overleaf is required. (Indicate clearly in the “To”
column if indefinite.)
4. Application for advances of salary must reach Salary Service Bureau at least six weeks prior to start of leave, unless arrangements have been to the
contrary.
5. An advance of salary must be applied for: (a) in the case of a Group II or III employee, if at least ten days’ leave is taken; (b) in the case of an officer or a
Group I employee, if at least 21days’ leave is taken; if such leave is taken over a period which includes a pay day.
6. Urgent Private Affairs leave – for use by Teachers and Defence Forces only.
1. Surname MUNYORO 2. First names TESTIMONY
3. Dept. & Stn. Code No. 4. Ministry/ Department 5. Station
APPLICANT TO COMPLETE BELOW: EMPLOYEE CODE NUMBER AND CHECK DIGIT, AND PERIOD OF LEAVE ONLY.
(IF E.C. No. AND / OR CHECK DIGIT ARE INCORRECT, FORM WILL BE REJECTED.)
S.S.B. USE ONLY
TYPE SECTION SUB-SECTION EMPLOYMENT CODE NUMBER C/D +/- O.P
1 2 3 4 5 7 8 14 15 16 17 20
Enter ‘O’ for
reversal of
TYPE OF LEAVE (Enter dates as 6 digits: e.g., 1st JUNE 1979 = 010679 previous entry
21
FROM TO +/- DAYS
VACATION
22 27 28 33 34 35 37
SICK
38 43 44 49 50 51 53
ANNUAL
54 59 60 65
SPECIAL
66 71 72 77
WITHOUT PAY
78 83 84 89
URGENT PRIVATE
AFFAIRS
(Note 6) 90 95 96 101
SCHOOL (Teacher)
102 107 108 113 114 115 117
ADVANCE OF SALARY
If required insert ‘Y’ in box 118
118
If Yes, state number of months………………………………………………………………………………………………...…
(Notes 4 & 5)
From the month of ………………………………………20…………… to………………………………………20………….
Nursing staff, Ministry of Health I certify that I will be vacating Government accommodation
And Members of the Z.R. Police
Prison Service and Air Force From……………………………………………………………………….to………………………………………………………… (inclusive)
Address whilst on leave …...……………………………………………………………………………………………………………………………………………………
………...……………………………………………………………………………………………………………………………………………….
Signature of applicant Recommended Approved
…….………………………… ……………………………………………………………….. ……………………………………………………………….
Date ……………………….... Date ……………………….... ………………………………. Date ……………………….... ……………………………...
FIRST SCHEDULE (Sections 19 and 23)
CERTIFICATE FOR SICK-LEAVE
PART 1
I certify that …………………………………………………………………………has been under my medical/dental
(name of applicant)
and that his/her illness prevented him/her attending to his/her duties during the period………………………………
to……………………………………and was not occasioned by misconduct or failure to take reasonable precautions;
(actual dates)
and I consider him/her to be unfit to discharge his/her duties and that it is necessary and indispensable for the recovery
of his/her health that he/she should have leave until………………………………for the purpose of………………..…
(state date)
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
...…..……………………………………………………..
Signature of Registered Medical Practitioner or Dental
Practitioner
……..……………………………………………………
Name in block letters of Registered Medical Practitioner
Or Dental Practitioner
Date ……………………………………… Qualifications ……………………………………………
Note.—Sick-leave in excess of 90 days in the case of an officer or employee can be granted only on the recommendation
of a medical board..
PART II
NOTIFICATION OF ABSENCE DUE TO INJURY OR ILLNESS
Note.—To be forwarded to the establishment officer of the department WITHIN 14 DAYS when absence from duty
will be longer than 14 days or the exact duration of sick-leave cannot be determined.
I certify that ……………………………………………………has been under my medical/dental treatment from
………………………………………………..and that owing to illness is unable to attend to his/her duties until
further notice.
...…..……………………………………………………..
Signature of Registered Medical Practitioner or Dental
Practitioner
……..……………………………………………………
Name in block letters of Registered Medical Practitioner
Or Dental Practitioner
Date ……………………………………… Qualifications ……………………………………………
