Civil Service Form No.

6 ANNEX A
Revised 2020
Stamp of Date of
Receipt

APPLICATION FOR LEAVE

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

DEPED-ECHAGUE WEST

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) 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

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

Vacation Leave Sick Leave For approval

Total Earned
For disapproval due to
Less this application

Balance - -

PRECIOUS C. PABON
Authorized Officer Authorized Officer

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

days with pay

days without pay

others (Specify)

RACHEL R. LLANA,PhD., CESO V

Schools Division Superintendent
 INSTRUCTIONS AND REQUIREMENTS
Application for any type of leave shall be made on this Form and to be accomplished d. In the absence of the BPO/TPO/PPO or the certification, a police
at least in duplicate with documentary requirements, as follows: report specifying the details of the occurrence of violence on the victim
and a medical certificate may be considered, at the discretion of the
1. Vacation leave* immediate 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 10. Rehabilitation leave* – up to 6 months
the form for purposes of securing travel authority and completing clearance from • Application shall be made within one (1) week from the time of the
money and work accountabilities. accident except when a longer period is warranted.
• Letter request supported by relevant reports such as the police report,
2. Mandatory/Forced leave if any,
Annual five-day vacation leave shall be forfeited if not taken during the year. In case • Medical certificate on the nature of the injuries, the course of
the scheduled leave has been cancelled in the exigency of the service by the head of treatment involved, and the need to undergo rest, recuperation, and
agency, it shall no longer be deducted from the accumulated vacation leave. rehabilitation, as the case may be.
Availment of one (1) day or more Vacation Leave (VL) shall be considered for • Written concurrence of a government physician should be obtained
complying the mandatory/forced leave subject to the conditions under Section 25, relative to the recommendation for rehabilitation if the attending
Rule XVI of the Omnibus Rules Implementing E.O. No. 292. physician 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 prior to the scheduled date of the gynecological surgery that will be
should 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
4. Maternity leave* – 105 days during confinement the agency shall be notified of said surgery.
• Proof of pregnancy e.g. ultrasound, doctor’s certificate on the expected date of • The application shall be accompanied by a medical certificate filled
delivery out by the proper medical authorities, e.g. the attending surgeon
• Accomplished Notice of Allocation of Maternity Leave Credits (CS Form No. 6a), if accompanied by a clinical summary reflecting the gynecological
needed disorder which shall be addressed or was addressed by the said
• Seconded female employees shall enjoy maternity leave with full pay in the surgery; the histopathological report; the operative technique used for
recipient agency. the surgery; the duration of the surgery including the perioperative
period (period of confinement around surgery); as well as the
5. Paternity leave – 7 days employees estimated period of 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
6. Special Privilege leave – 3 days • The special emergency leave can be applied for a maximum of five
It shall be filed/approved for at least one (1) week prior to availment, except on (5) straight working days or staggered basis within thirty (30) days from
emergency cases. Special privilege leave within the Philippines or abroad shall be the actual occurrence of the natural calamity/disaster. Said privilege
indicated in the form for purposes of securing travel authority and completing shall be enjoyed once a year, not in every instance of calamity or
clearance from money and work accountabilities. 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 going on such granted thereof. Said verification shall include: validation of place of
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 declaration of
8. Study leave* – up to 6 months calamity area by the proper government agency; and such other proofs
• Shall meet the agency’s internal requirements, if any; 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 employee’s return from the 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 • Application for adoption leave shall be filed with an authenticated
been filed with the said office shall be sufficient to support the application for the ten- copy of the Pre-Adoptive Placement Authority issued by the
day leave; or 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).