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Civil Service Form No.

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

REGION VIII
SCHOOLS DIVISION OF NORTHERN SAMAR

APPLICATION FOR
LEAVE
1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
DEPED/ BINOG ES TAGROS PAZ ESPELIMBERGO

3. Date of Filling: FEBRUARY 12, 2024 4. POSITION TEACHER III 5. SALARY PHP 31,949.00

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 FLU
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

TWO (2) Days Not Requested

INCLUSIVE DATES
FEBRUARY 7-8, 2024 PAZ E. TAGROS
(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
MARY ANN P. BIANES
CARMENCITA L. MARTIRES School Principal
cc

(Authorized Officer) (Authorized Officer)

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


days with pay
days without pay
others (Specify)

REY F. BULAWAN, EdD


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

* 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).

Stamp of Date of Receipt

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)
DEPARTMENT OF EDUCATION ARNIÑO ROGER DE GUIA

3. Date of Filling: 4. POSITION MASTER TEACHER III 5. SALARY PHP 55, 799.00

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)
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


1 DAY Not Requested
INCLUSIVE DATES Requested
NOVEMBER 21, 2022
(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
GINALYN H. DE GUIA
School Principal
(Authorized Officer) (Authorized Officer)

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


days with pay
days without pay
others (Specify)

LANI H. CERVANTES, CESO VI


Schools Division Superintendent
(Authorized Official)

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