(vt Service Form No.6 Republic of the Philippines DEPARTMENT OF HEALTH : CENTRAL VISAYAS CENTER for HEALTH DEVELOPMENT ° (Osmeria Boulevard, Cebu City, 6000 Phiiooines APPLICATION FOR LEAVE f. OFFICEDEPARTMENT 2 NAME (Last Fist) ‘wade Is. DATE OF FILING _ [4 POSITION __ _ 5. SALARY _ 7 6. DETAILS OF APPLICATION ISA TYPE OF LEAVE TO BE AVAILED OF J68 DETALS OF LEAVE Di Vacation Leave et 08 ronntue ae nein 0. 22) In casa of Vacaion/SpocialPrivieae Leave CO mandatryForced Leaves text omibe Rainey eo 20 | CJ Wein ine Priopines DSi Leave 4 et oma es penetg 0 M22 Cana (spect Le Caterity Leave ae wii, od 85 sncoee of Sick Leove TPatemity Leave sno nica We ho we Cin Hospital (Speci tess) Cspecial Privilege Leavers: tev, omis Rimmer 2 | CloutPatent(Specty ness) Cissole Parent Leave iis 1 cseuewe te ana _ Cstuty Leave ino urna eset Me 2 incoeeof Special Leave Benef fo Wornen CtoDay VAWC Leeve si saz0scusse 1 m8 (Specty tess) CRenebiitaion Priiage x 3 te, is einen 0M 09 oe Csspecial Leave Benefits for Women pave arnvcscwcve 501 | incase af Stay Laave special Emergency (Calamity) Leave sci 24212 woman; |] Completion of Masters Degree adoption Leaversh ee Cl eanstoard Examinaion Review | ter purpose: tes: CMoneization of Leave Cres Ci termina! Leave [6.C NUMBER OF WORKING DAYS APPLIED FOR |e. COMMUTATION ee Cot Requests INCLUSIVE DATES Ci reauestes ‘Cignature ot Appian, 7, DETAILS OF ACTION ON APPLICATION [A CERTIFICATION OF LEAVE CREDITS T.8 RECOMMENDATION As of _ _ O Fer approval Vacation Leave, Sick Leave Dror cisapproval due to — [rotei camed | Less tis apateaton | Balance fc APPROVED FOR 70 DISAPPROVED DUE TO ‘days with pay days without pay - others (Specty) =Application for any type of leave shall be made on this Form and to be accomplished at least in duplicate with documentary requiremens, as follows: 4. Vacation leave" INSTRUCTIONS AND REQUIREMENTS | TPO or PPO has been fied withthe said office shal be sufficient to support the appication forthe tena = Inthe absence of the BPO/TPOP cation, a police ‘report specifying the details of the occurrence of violence on the Victim and 2 medical certfcate may be considered, at the It shal be fled fve (6) days in advance, whenever possible, ofthe discreion ofthe immediate supericor uf > vsman employee effective date of such leave. Yaca‘on eave win in the Philppines or concerned abroad shal be indicated in the fxn for purposes of securg travel authonty and completing clearance from money and work 10. Rehabilitation leave" - up to 6 months accountabites, + Applicaton shal be made within one (1) wee om the time ofthe ancient except when a longer perad is ware. 2. MandatoryiForced leave « Leiter request supporied by relevent reports such 2 the police Annual five-day vacation leave shall be foreted if not taken ding the report, i any. Yea Incase the scheduled eave has been canceled inthe exigency + Necical ceifcate on the ratue of the injures, the couse of Ofte service bythe head agency. shal na longer be deducted trom treatment invowed, and te need to undergo rest, recuperation, and the accumulated vacation ea:s. Avaiment of one (1) day oF more rehabilitation, asthe case may be Vacation Leave (VL) sili os considered for complying the ‘+ Written concurrence of a government physician should be obtained mandetoryiorcd leave subject the condions under Section 26, Rule rave 'o the teoonmondaton ‘er refvoiiaton I Be sending XV ofthe Omnibus Rules inoiinenting €.0. No, 282 prysiclan isa private practioner, pat-w", he duraton ofthe tod of rehabilitation 3. Sick eavet + Itshallbe fled immediato'y upon employee's etun rom such eave, 44, Special eave benefits for women* up to 2 months «+ I fled in advance or exceeding five (5) days, appiation shall be ‘The apolcation maybe fed in advance, tats. least five (6) days accompanied by 2 medica ceriicate. In case medical consutaion prior tothe scheduled date of the gynecoogica! suger that wil De was not avaled of, an afdayit sould be executed by an appcant. undergone by he employee. incase of emergency the application {or special leave shal te fled immediete'y upan employee's return 4. Maternity leave - 105 days bul during confinement the agency shal e noted of said surgery. + Proof of pregnancy e.g. ultrasound, doctor's certificate on the ‘© The application shall ba accompanied by a macical certificate filed expected date of delivery cut by the proper medical authortes,e3, the atending surgeon + Accomplished Notee of Alocation of Matemity Leave Credits (CS accompanied by a cliical summery relecting the gynecological Form No. 6). needed disorder which shall be addressed or was adiressed by the said + Seconded female employees shal enjoy maternity leave wih fl pay ‘surgery; the histopathological report ho oporaive technique used inthe reipiont agency. for the surgery, the ration of the surgery incuding the per operative period (period of confrement 2 yey) aswell as 8. Paternity leave -7 days the employees estimated period ofr. ‘ne same. Proof of child's delvery eg. tt certificate, modical cartfeate and marnage contract 12. Spacial Emergency (Calamity) eave ~up te 5 days ‘= The special emergency ieave can be appl fer a maximum of five 6. Special Privilege leave ~ 3 days (6) straight working days or staggered basis win tity (30) days It shall be filelapproved fora! east one (1) week prior to avaiiment, from the actual ooourrence of the natural clamiyiisaster, Said fercepl on emergency cases Special pivege leave wibin the priviege shall be enjoyed once a year ci in every Instance of Philppines or abroad shat Le indicated in the form for puposes of Calamity or disaster seouting travel authority and co-mpleting clearance from money and work «© The head of office shal take ul respons ‘ws grant special accounlablies emergency leave and verification of ine englo. 5 alight to be ‘grated thereof. Seid verication shaline-ud> alan of place of 7. Solo Parent leave ~7 days residence based on latest avalable vecs': oi the affected It shall be fled in advance or whenever possible five (6) days before ‘employee; verification tal the placa ofresklence is oovered in the going on such leave wth updotedt Sota Parent denicaton Car dladarsbon of alam aoa byte proper govsrxment agency, and sh other proofs a8 may be necessary 8. Study eave" - upto 6 months ” 7 «Shall mae the agency's interna requirements, any; 43, Monetization of leave credits + Contract between the agency head or authorized representative and Agpication for monetization of fy x more of the the employee concerned. accumulated leave credits shall be aacon. ©" ater request to the head ofthe agency stating the valid ane 2 eag0ns, 9. VAWC leave ~ 10 days It shall be fled in advance or immediatly upon the woman 14. Terminal eave" employee's retum from sucn leave. Proot of employee's resignation or retiemer + tsallbeaccornparied by ary ofthe folowing supporting documents: sevice (8PO) obtained from the barangay; ‘on Order (TPOIPPO) obtained tom 15. Adoption Leave 6. Ifthe protection order isnot vet issued bythe barangay othe cour, 4 cetfication issued by the Punong Barangay/Kagawad or Prosecutor 0° the Clerk cf Court thatthe application for the BPO, ‘Applicaton for adoption leave ka! ve Ned wi an authenticated copy of the Pre-Adoptive Placement Autnon, issued by the Department of Social Welare and Development ;OSWO). * Forlesve of absence fr tity (20 clea wotkelted acoountabes days or more and termina leave, aplication sal be accompanied by a cearan usuario CSC Memorandum Circular No. 2,8, 1985)