Civil Service Form No.

6
Revised 2020 ANNEX A
Republic of the Philippines
Department of Education
J.P. Laurel Street, Kidapawan City Stamp of Date of Receipt

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 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. In case of Vacation/Special Privilege Leave:
292)
Within the Philippines __________________________
Mandatory/Forced Leave(Sec. 25, Rule XVI, Omnibus Rules Implementing Abroad (Specify) ______________________________ In
E.O. No. 292)
case of Sick Leave:
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No.
In Hospital (Specify Illness) _____________________
292) Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE
Out Patient (Specify Illness) _____________________
and SSS)
_____________________________________________ In case of
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended)
Special Leave Benefits for Women:
Special Privilege Leave(Sec. 21, Rule XVI, Omnibus Rules Implementing
E.O. No. 292)
(Specify Illness) ________________________________
_____________________________________________ In case of
Solo Parent Leave(RA No. 8972 / CSC MC No. 8, s. 2004)
Study Leave:
Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292)
Completion of Master's Degree
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005)
BAR/Board Examination Review Other
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing
E.O. No. 292) purpose:
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) Monetization of Leave Credits

Special Emergency (Calamity) Leave (CSC MC No. 2, s. 2012, as amended) Terminal Leave

Adoption Leave(R.A. No. 8552)

Others:
_____________________________________
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 _______________________

For approval
Vacation Leave Sick Leave
For disapproval due to _________________________
Total Earned ___________________________________________
Less this application ___________________________________________
___________________________________________
Balance

___________________________________________
JUVY LYN L. MANGIBUNONG (Authorized Officer)
Administrative Officer IV
(Authorized Officer)
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________ _______ others (Specify)
___________________________________________

DR. NATIVIDAD G. OCON, CESO VI

OIC - Schools Division Superintendent
(Authorized Official)
 INSTRUCTIONS AND REQUIREMENTS
Application for any type of leave shall be made on this Form and to considered, at the discretion of the immediate supervisor of
beaccomplished at least in duplicate with documentary the woman employee concerned.
requirements, as follows: 10. Rehabilitation leave* – up to 6 months
• Application shall be made within one (1) week from the time of
1. Vacation leave* the accident except when a longer period is warranted.
It shall be filed five (5) days in advance, whenever possible, of the • Letter request supported by relevant reports such as the police
effective date of such leave. Vacation leave within in the report, if any,
Philippines or abroad shall be indicated in the form for purposes of
• Medical certificate on the nature of the injuries, the course of
securing travel authority and completing clearance from money treatment involved, and the need to undergo rest, recuperation,
and work accountabilities. and rehabilitation, as the case may be.
2. Mandatory/Forced leave • Written concurrence of a government physician should be
Annual five-day vacation leave shall be forfeited if not taken during obtained relative to the recommendation for rehabilitation if the
the year. In case the scheduled leave has been cancelled in the attending physician is a private practitioner, particularly on the
exigency of the service by the head of agency, it shall no longer be duration of the period of rehabilitation.
deducted from the accumulated vacation leave. Availment of one
(1) day or more Vacation Leave (VL) shall be considered for 11. Special leave benefits for women* – up to 2 months
complying the mandatory/forced leave subject to the conditions • The application may be filed in advance, that is, at least five (5)
under Section 25, Rule XVI of the Omnibus Rules Implementing days prior to the scheduled date of the gynecological surgery
E.O. No. 292. that will be undergone by the employee. In case of emergency,
the application for special leave shall be filed immediately upon
3. Sick leave* employee’s return but during confinement the agency shall be
• It shall be filed immediately upon employee's return from such notified of said surgery.
leave. • The application shall be accompanied by a medical certificate
• If filed in advance or exceeding five (5) days, application shall be filled out by the proper medical authorities, e.g. the attending
accompanied by a medical certificate. In case medical surgeon accompanied by a clinical summary reflecting the
consultation was not availed of, an affidavit should be executed gynecological disorder which shall be addressed or was
by an applicant. addressed by the said surgery; the histopathological report; the
4. Maternity leave* – 105 days operative technique used for the surgery; the duration of the
• Proof of pregnancy e.g. ultrasound, doctor’s certificate on the surgery including the perioperative period (period of
expected date of delivery confinement around surgery); as well as the employees
estimated period of recuperation for the same.
• Accomplished Notice of Allocation of Maternity Leave Credits (CS
Form No. 6a), if needed
12. Special Emergency (Calamity) leave – up to 5 days
• Seconded female employees shall enjoy maternity leave with full
pay in the recipient agency. • The special emergency leave can be applied for a maximum of
5. Paternity leave – 7 days five (5) straight working days or staggered basis within thirty (30)
Proof of child’s delivery e.g. birth certificate, medical certificate and days from the actual occurrence of the natural calamity/disaster.
Said privilege shall be enjoyed once a year, not in every instance
marriage contract
of calamity or disaster.
6. Special Privilege leave – 3 days • The head of office shall take full responsibility for the grant of
It shall be filed/approved for at least one (1) week prior to special emergency leave and verification of the employee’s
availment, except on emergency cases. Special privilege leave eligibility to be granted thereof. Said verification shall include:
within the Philippines or abroad shall be indicated in the form for validation of place of residence based on latest available records
purposes of securing travel authority and completing clearance of the affected employee; verification that the place of residence
from money and work accountabilities. is covered in the declaration of calamity area by the proper
government agency; and such other proofs as may be necessary.
7. Solo Parent leave – 7 days
It shall be filed in advance or whenever possible five (5) days before 13. Monetization of leave credits
going on such leave with updated Solo Parent Identification Card. Application for monetization of fifty percent (50%) or more of the
accumulated leave credits shall be accompanied by letter request
8. Study leave* – up to 6 months
to the head of the agency stating the valid and justifiable reasons.
• Shall meet the agency’s internal requirements, if any;
• Contract between the agency head or authorized representative 14. Terminal leave*
and the employee concerned. Proof of employee’s resignation or retirement or separation from
9. VAWC leave – 10 days the service.
• It shall be filed in advance or immediately upon the woman
employee’s return from such leave. 15. Adoption Leave
• It shall be accompanied by any of the following supporting Application for adoption leave shall be filed with an
documents: authenticated copy of the Pre-Adoptive Placement Authority
a. Barangay Protection Order (BPO) obtained from the barangay; issued by the Department of Social Welfare and Development
b. Temporary/Permanent Protection Order (TPO/PPO) obtained (DSWD).
from the court;
c. If the protection order is not yet issued by the barangay or the
court, a certification issued by the Punong Barangay/Kagawad
or Prosecutor or the Clerk of Court that the application for the
BPO, TPO or PPO has been filed with the said office shall be
sufficient to support the application for the ten-day leave; or
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 medical certificate may be

* 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).
* 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).