Republic of the Philippines

Department of Education Republic of the Philippines

Region VI - Western Visayas Department of Education
SCHOOLS DIVISION OF ILOILO Region VI - Western Visayas
Luna St., La Paz, Iloilo City SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City

CHECKLIST FOR SICK LEAVE (30 DAYS TO ONE YEAR)

Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Application Letter for Sick Leave(stating the
sickness/disease/s)
3. CSC Form 6
4. CSC Form 41 ( Medical Certificate with
documentary stamp)
5. Last day of service
6. School Clearance
7. Machine Copy of Leave Cards and Certified
Correct by the Principal
CHECKLIST FOR EXPANDED MATERNITY LEAVE
(105 DAYS)
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Application Letter for Maternity Leave (30
days before the expected date of delivery)
3. CSC Form 6
4. CSC form 41 ( Medical Certificate with
documentary stamp)
5. Last day of service
6. Division Clearance
7. Special Order for Maternity Leave

Republic of the Philippines

Department of Education Republic of the Philippines
Region VI - Western Visayas Department of Education
SCHOOLS DIVISION OF ILOILO Region VI - Western Visayas
Luna St., La Paz, Iloilo City SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City

CHECKLIST FOR SICK LEAVE IN EXCESS OF FIVE (5) SUCCESSIVE

DAYS
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. CSC Form 6
2. CSC form 41 ( Medical Certificate with documentary
stamp)
3. Machine Copy of Leave Cards and Certified Correct by
the Principal
*shall be filed immediately upon the
employee’s return from such leave
CHECKLIST FOR PERSONAL LEAVE
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. CSC Form 6
*Must be filled 5 days before the scheduled
leave
*Must be deducted against payroll since
service credits can only be used to offset
against sick leave (DepED Order 53 s. 2003)

Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City

CHECKLIST FOR REINSTATEMENT FROM SICK LEAVE

CHECKLIST FOR SICK LEAVE (1 DAY)
(16 days and above)

Name: _____________________________________
Name: _____________________________________
Position: ____________________________________
Position: ____________________________________
School/District: _______________________________
School/District: _______________________________

1. CSC Form 6
*shall be filed immediately upon the
employee’s return from such leave
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR SPECIAL LEAVE FOR WOMEN
(MAGNA CARTA)
1. Indorsement letter from the Principal/PSDS
2. Letter of application for return of duty
3. First day of service of actual service
4. Form 211 (Prescribed medical form certificate
stating that the teacher/employee is physically
fit
5. Special Order for Reinstatement(including
Attachment)
6. Birth Certificate with registry/death certificate
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City

Name: _____________________________________
CHECKLIST FOR REINSTATEMENT FROM MATERNITY
Position: ____________________________________
LEAVE
School/District: _______________________________

Name: _____________________________________
1. Indorsement letter from the Principal/PSDS
Position: ____________________________________
2. CSC Form 6
School/District: _______________________________
3. CSC form 41 ( Medical Certificate with
documentary stamp)
4. Last day of service
1. Indorsement letter from the Principal/PSDS
5. Division Clearance
2. Letter of application for return to duty
6. Medical abstract
3. First day of actual service
4. Form 211 (Prescribed medical form certificate
stating that the teacher/employee physically fit
5. Special Order for Reinstatement
*It is required that the CSC Form 41 must be
concurred by our Medical Officer
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
Republic of the Philippines
Department of Education
CHECKLIST FOR PERMIT TO TRAVEL ABROAD (45 Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
DAYS BEFORE EXPECTED TRAVEL DATE)
Luna St., La Paz, Iloilo City

Name: _____________________________________
Position: ____________________________________ CHECKLIST FOR REINSTATEMENT FROM VACATION
School/District: _______________________________ TRAVEL ABROAD LEAVE

1. Indorsement letter from the Principal/PSDS Name: _____________________________________

2.Letter of application for travel abroad
3.Form 6
4. Division Clearance
5. Certification of No Pendency of Case
6. Last day of service
7. Certification of expected date of departure
8. Certificate of Employment
9. Certificate of No administrative case
10. Certification of leave credits
11. Certification that his/her absence shall not
hamper the operational efficiency of the
agency
12. Designation as to who will handle his/her
responsibilities
*45 days before departure
*DepED Order 43 s. 2014
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Letter of application for return to duty
3. First day of actual service
4. Form 211 (Prescribed medical form certificate
stating that the teacher/employee physically
fit
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR PERMIT TO STUDY

Name: _____________________________________
Position: ____________________________________
Republic of the Philippines
Department of Education
School/District: _______________________________
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO 1. Indorsement letter from the Principal/PSDS
Luna St., La Paz, Iloilo City
2. Letter request for permit to study

CHECKLIST FOR VACATION LEAVE (1 DAY OR MORE)

3. School curriculum signed by the Registrar /
Name: _____________________________________
Dean of the School
Position: ____________________________________
School/District: _______________________________
1. Form 6
*Filed 5 days before the actual leave
*Sec 52 CSC Memo. No. 41, s. 1998
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR RESIGNATION
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Teacher’s resignation letter thru the
Principal/PSDS (30 days before the effective
date of resignation
3. Division clearance
4. Last day of service
5. Sworn statement of assets and liabilities
6. Performance rating
7. Certification of No Pending Administrative
Case
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR CHANGE OF NAME
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Letter of application for change of name
3. Certificate of marriage with registry number
4. Special Order for Change of Name
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR STUDY LEAVE UNDER R. A. 4670
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Latest performance rating
3. Form 211 (Medical Form)
4. Form 6 Application for leave
5. Division clearance
6. Certification of No Administrative case
7. Approved permit to study
8. Certification from the Principal/PSDS that
services can be dispensed with
9. Study leave agreement
10. Last day of actual service
11. Transcript of records
12. Certification that he/she has not availed of
R.A. 4670 before
13. Sworn statement of Assets and Liabilities
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR RETIREMENT
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement
2. Application for Retirement
3. Updated service record
4. Last pay slip (NOSI, if any)
5. Division Clearance
6. Certification of LAW/OP
7. Certification of Provident fund clearance
8. Certification of no pending administrative
case
9. Certification of No Pendency of cases
10. Declaration of pendency / non- pendency of
case
Submit in three (3) Copies
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR SURVIVORSHIP BENEFITS
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement
2. Application for Survivorship
3. Death Certificate
4. Marriage Contract
5. Birth Certificate of Children
6. Proofs of surviving legal heirs
7. Updated service record
8. Last pay slip, (NOSI if any)
9. Clearance
10. Certification of LAW/OP
11. Certification of Provident Fund Clearance
12. Certification of no pending administrative
case
13. Ombudsman clearance
14. CSC clearance
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR 6 MONTHS STUDY LEAVE EXCLUDING
THE TEACHING PROFESSION
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Indorsement letter from the Principal/PSDS
2. Form 6 Application for Leave
3. Division Clearance
4. Certification of No Administrative Case
5. Study Leave Agreement
6. IPCRF
7. Sworn Statement of Assets and Liabilities
8. Form 211
9. Application Letter
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR REQUEST FOR ELECTION SERVICE
CREDITS
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Letter request (addressed to the SDS) duly
signed by the School Head
2. Special Order with list of teachers/claimants
3. Form 48 per teacher
4. BEI appointment and/or Comelec certification
per teacher (Original copy)
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR K TO 12 CREDENTIAL
TRAININGS/WORKSHOPS AND/OR OTHER
SEMINAR/WORKSHOPS SERVICE CREDIT CLAIM
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Letter request (addressed to the SDS)
2. Special Order with list of teachers/claimants
3. DepED Memorandum
4. Form 48 per teacher
5. Certificate of training/participation (Certificate
of appearance is invalid)
6. Accomplishment report per teacher
Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City
CHECKLIST FOR BRIGADA ESKWELA SERVICE CREDITS
Name: _____________________________________
Position: ____________________________________
School/District: _______________________________
1. Letter request (addressed to the SDS) duly
signed by the School Head
2. Special Order with list of teachers/claimants
3. DepED Memorandum
4. Form 48 per teacher
5. MOVs
6. Accomplishment report per teacher
 Republic of the Philippines
Department of Education
Region VI - Western Visayas
SCHOOLS DIVISION OF ILOILO
Luna St., La Paz, Iloilo City

CHECKLIST FOR REQUEST FOR SERVICE CREDITS

(ACADEMIC PROGRAMS/ACTIVITIES that fall on
Saturdays, Sundays or Holiday being granted with
service credit)

Name: _____________________________________
Position: ____________________________________
School/District: _______________________________

1. Letter request (addressed to the SDS) duly

signed by the School Head
2. Special Order with list of teachers/claimants
3. DepED Memorandum
4. Form 48 per teacher
5. Accomplishment report per teacher