CS Form No. 6 Application For Leave

Civil Service Form No.
6
Revised 2020
Republic of the Philippines

Department of Education Stamp of Date of Receipt
Region VIII
SCHOOLS DIVISION OF SAMAR
APPLICATION FOR LEAVE

1. OFFICE/DISTRICT/SCHOOL & SCHOOL ID 2. NAME : (Last) (First) (Middle)
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) _____________________________________________
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

Not Requested
Requested
INCLUSIVE DATES (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
ROTHEL R. CALINAO FRANCIA A. TAN

___________________________________________
Administrative Officer IV Division Chief/Immediate Supervisor
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
JOEL A. ZARTIGA, PhD

_________________________________
Assistant Schools Division Superintendent
Civil Service Form No. 6
Revised 2020

Region VIII

✘ Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No. 292) Within the Philippines __________________________
Other purpose:
_____________________________________ Terminal Leave
6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

Not Requested
Requested
INCLUSIVE DATES (Signature of Applicant)

Total Earned ___________________________________________
Balance
ROTHEL R. CALINAO ___________________________________________

Administrative Officer IV (Signature of School Head)

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________

_________________________________
Revised 2020

Region VIII

Other purpose:
_____________________________________ Terminal Leave
'6.C NUMBER IF WORKING DAYS APPLIED FOR 6.D COMMUTATION

________________________________________ Not Requested
INCLUSIVE DATES Requested
________________________________________
(Signature of Applicant)

Total Earned ___________________________________________
Balance
ROTHEL R. CALINAO DEOGENE U. DAPURAN, PhD

___________________________________________
Administrative Officer IV (Signature of District Supervisor)

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________

_________________________________
INSTRUCTIONS AND REQUIREMENTS
Application for any type of leave shall be made on this Form and to be c. If the protection order is not yet issued by the barangay or the
accomplished at least in duplicate with documentary requirements, as court, a certification issued by the Punong Barangay/Kagawad
follows:
* For leave of absence for thirty (30) calendar days or more and terminal leave, application or Prosecutor
shall or the by
be accompanied Clerk of Court from
a clearance that money,
the application for the
property and
work-related accountabilities (pursuant to CSC Memorandum Circular No. 2, s. 1985). BPO, TPO or PPO has been filed with the said office shall be
1. Vacation leave* sufficient to support the application for the ten-day leave; or
It shall be filed five (5) days in advance, whenever possible, of the d. In the absence of the BPO/TPO/PPO or the certification, a police
effective date of such leave. Vacation leave within in the Philippines report specifying the details of the occurrence of violence on the
or abroad shall be indicated in the form for purposes of securing travel victim and a medical certificate may be considered, at the
authority and completing clearance from money and work discretion of the immediate supervisor of the woman employee
accountabilities. concerned.
2. Mandatory/Forced leave 10. Rehabilitation leave* – up to 6 months

Annual five-day vacation leave shall be forfeited if not taken during  Application shall be made within one (1) week from the time of the
the year. In case the scheduled leave has been cancelled in the accident except when a longer period is warranted.
exigency of the service by the head of agency, it shall no longer be  Letter request supported by relevant reports such as the police
deducted from the accumulated vacation leave. Availment of one (1) report, if any,
day or more Vacation Leave (VL) shall be considered for complying  Medical certificate on the nature of the injuries, the course of
the mandatory/forced leave subject to the conditions under Section treatment involved, and the need to undergo rest, recuperation,
25, Rule XVI of the Omnibus Rules Implementing E.O. No. 292. and rehabilitation, as the case may be.
 Written concurrence of a government physician should be
3. Sick leave* obtained relative to the recommendation for rehabilitation if the
 It shall be filed immediately upon employee's return from such attending physician is a private practitioner, particularly on the
leave. duration of the period of rehabilitation.
 If filed in advance or exceeding five (5) days, application shall be
accompanied by a medical certificate. In case medical consultation 11. Special leave benefits for women* – up to 2 months
was not availed of, an affidavit should be executed by an applicant.  The application may be filed in advance, that is, at least five (5)
days prior to the scheduled date of the gynecological surgery that
4. Maternity leave* – 105 days will be undergone by the employee. In case of emergency, the
 Proof of pregnancy e.g. ultrasound, doctor’s certificate on the application for special leave shall be filed immediately upon
expected date of delivery employee’s return but during confinement the agency shall be
 Accomplished Notice of Allocation of Maternity Leave Credits (CS notified of said surgery.
Form No. 6a), if needed  The application shall be accompanied by a medical certificate
 Seconded female employees shall enjoy maternity leave with full filled out by the proper medical authorities, e.g. the attending
pay in the recipient agency. surgeon accompanied by a clinical summary reflecting the
gynecological disorder which shall be addressed or was
5. Paternity leave – 7 days addressed by the said surgery; the histopathological report; the
Proof of child’s delivery e.g. birth certificate, medical certificate and operative technique used for the surgery; the duration of the
marriage contract surgery including the peri-operative period (period of confinement
around surgery); as well as the employees estimated period of
6. Special Privilege leave – 3 days recuperation for the same.
It shall be filed/approved for at least one (1) week prior to availment,
except on emergency cases. Special privilege leave within the 12. Special Emergency (Calamity) leave – up to 5 days
Philippines or abroad shall be indicated in the form for purposes of  The special emergency leave can be applied for a maximum of
securing travel authority and completing clearance from money and five (5) straight working days or staggered basis within thirty (30)
work accountabilities. days from the actual occurrence of the natural calamity/disaster.
Said privilege shall be enjoyed once a year, not in every instance
7. Solo Parent leave – 7 days of calamity or disaster.
It shall be filed in advance or whenever possible five (5) days before  The head of office shall take full responsibility for the grant of
going on such leave with updated Solo Parent Identification Card. special emergency leave and verification of the employee’s
eligibility to be granted thereof. Said verification shall include:
8. Study leave* – up to 6 months validation of place of residence based on latest available records
 Shall meet the agency’s internal requirements, if any; of the affected employee; verification that the place of residence
 Contract between the agency head or authorized representative is covered in the declaration of calamity area by the proper
and the employee concerned. government agency; and such other proofs as may be necessary.
9. VAWC leave – 10 days 13. Monetization of leave credits

 It shall be filed in advance or immediately upon the woman Application for monetization of fifty percent (50%) or more of the
employee’s return from such leave. accumulated leave credits shall be accompanied by letter request to
 It shall be accompanied by any of the following supporting the head of the agency stating the valid and justifiable reasons.
documents:
a. Barangay Protection Order (BPO) obtained from the barangay; 14. Terminal leave*
b. Temporary/Permanent Protection Order (TPO/PPO) obtained Proof of employee’s resignation or retirement or separation from the
from the court; service.
Revised 2020

Region VIII

Other purpose:
_____________________________________ Terminal Leave
6.C NUMBER IF WORKING DAYS APPLIED FOR 6.D COMMUTATION

________________________________________ Not Requested
________________________________________

Total Earned ___________________________________________
Balance
___________________________________________
Administrative Officer School Head/Division Chief/Immediate Supervisor

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
ELOISA R. ZARTIGA
_________________________________
EPS - OIC - Office of the Assistant Schools Division Superintendent
Revised 2020

Region VIII

Other purpose:
_____________________________________ Terminal Leave
'6.C NUMBER IF WORKING DAYS APPLIED FOR 6.D COMMUTATION

________________________________________ Not Requested
________________________________________

Total Earned ___________________________________________
Balance
ROTHEL R. CALINAO ELOISA R. ZARTIGA

___________________________________________
Administrative Officer IV EPS - OIC - Office of the Assistant Schools Division Superintendent

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify) ___________________________________________
CARMELA R. TAMAYO, EdD, CESO V

_________________________________
Schools Division Superintendent

CS Form No. 6 Application For Leave

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Civil Service Form No.

Republic of the Philippines

APPLICATION FOR LEAVE

3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________

6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

INCLUSIVE DATES (Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

ROTHEL R. CALINAO FRANCIA A. TAN

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

JOEL A. ZARTIGA, PhD

Republic of the Philippines

APPLICATION FOR LEAVE

3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________

6.C NUMBER OF WORKING DAYS APPLIED FOR 6.D COMMUTATION

INCLUSIVE DATES (Signature of Applicant)

7. DETAILS OF ACTION ON APPLICATION

ROTHEL R. CALINAO ___________________________________________

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

JOEL A. ZARTIGA, PhD

Republic of the Philippines

APPLICATION FOR LEAVE

3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________

'6.C NUMBER IF WORKING DAYS APPLIED FOR 6.D COMMUTATION

7. DETAILS OF ACTION ON APPLICATION

ROTHEL R. CALINAO DEOGENE U. DAPURAN, PhD

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

JOEL A. ZARTIGA, PhD

2. Mandatory/Forced leave 10. Rehabilitation leave* – up to 6 months

9. VAWC leave – 10 days 13. Monetization of leave credits

Republic of the Philippines

APPLICATION FOR LEAVE

3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________

6.C NUMBER IF WORKING DAYS APPLIED FOR 6.D COMMUTATION

7. DETAILS OF ACTION ON APPLICATION

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

Republic of the Philippines

APPLICATION FOR LEAVE

3. DATE OF FILING ______________ 4. POSITION _____________________________ 5. SALARY _______________

'6.C NUMBER IF WORKING DAYS APPLIED FOR 6.D COMMUTATION

7. DETAILS OF ACTION ON APPLICATION

ROTHEL R. CALINAO ELOISA R. ZARTIGA

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

CARMELA R. TAMAYO, EdD, CESO V

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