Civil Service Form No.

6
Revised 2020

Republic of the Philippines

Department of Education
Region V
SCHOOLS DIVISION OFFICE OF CAMARINES SUR

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last)
Principal II (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
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 May 2021 ___________________________________________

___________________________________________
Administrative Officer IV-HRMO (Authorized Officer)

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

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
MARIA DIVINA H. CALLEJA MAR
_______ others (Specify) ___________________________________________
3

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

Date

The Schools Division Superintendent

Division of Camarines Sur
San Jose, Camarines Sur
(Thru Channels)

Madam:

This is to apply for _______ calendar days of Sick/Vacation/Maternity Leave of Absence from
____________ to _____________, 2021, inclusive. This will further request my absence without pay,
if any, be offsetted by my service credits earned.

The following are the informational data required in Division Letter No. 57, dated October 29,
1966, viz;

1. Station Assignment:
2. First Day of Service during the year:
3. Absences if any, prior to this leave:
4. Monthly Salary:
5. Status (Permanent/Provisional)
6. Specific Period of Leave:
7. Permanent/Provisional Appointment effectivity:

Very truly yours,

Signature Over Printed Name

Designation:

CP No.:
School ID:

Incl.: CS Form 6
CS Form 41(with documentary stamp)
CS Form48 covering months with service credits
Clearance

CONTENTS NOTED:

School Head

1st Indorsement
Tinambac North District, ___________________2021

Respectfully forwarded to the Schools Division Superintendent, Division of Camarines Sur, San Jose,
Pili, Camarines Sur, the application for return for leave together with the inclosures of Mr./Ms./
_______________________ this district recommending approval.

GIL C. GRAVANTE
Public Schools District Supervisor
 Department of Education
Region V
Division of Camarines Sur
TINAMBAC NORTH DISTRICT

Date

The Schools Division Superintendent

Division of Camarines Sur
San Jose, Camarines Sur
(Thru Channels)

Madam:

I have the honor to apply for return to duty effective ____________________, 2021.

I was on Maternity/Sick/Vacation Leave of absence for the period from ___________________,

2021 to _______________________, 2021, inclusive. The required Medical Certificate, Birth
Certificate, etc. are herewith enclosed.

Very truly yours,

Designation:
Status:
Emp. No.:
CP No.:
School ID:

Incl.: CS Form 211(with documentary stamp)

Birth Certificate (2 copies)
Marriage Contract (1 copy)

CONTENTS NOTED:

School Head

1st Indorsement
Tinambac North District, ___________________2021

Respectfully forwarded to the Schools Division Superintendent, Division of Camarines Sur, San Jose,
Pili, Camarines Sur, the application for return to duty together with the inclosures of
______________________ effective _______________________, 2021 recommending approval.

GIL C. GRAVANTE
Public Schools District Supervisor
CS Form No. 211
Revised 2018

MEDICAL CERTIFICATE
(For Employment)

INSTRUCTIONS
a. This medical certificate should be accomplished by a licensed government physician.
b. Attach this certificate to original appointment, transfer and reemployment.
c. The results of the following pre-employment medical/physical/psychological
must be attached to this form:
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination (if applicable)

FOR THE PROPOSED APPOINTEE

NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS

ADDRESS

AGE SEX CIVIL STATUS PROPOSED POSITION

FOR THE LICENSED GOVERNMENT PHYSICIAN

I hereby certify that I have reviewed and evaluated the attached examination results,
personally examined the above named individual and found him/her to be physically and medically
£FIT / £UNFIT for employment.
SIGNATURE over PRINTED NAME OF LICENSED GOVERNMENT PHYSICIAN: OTHER INFORMATION ABOUT THE
PROPOSED APPOINTEE

AGENCY/Affiliation of Licensed Government Physician:

LICENSE NO. HEIGHT (M) WEIGHT (KG) BLOOD

Bare Foot Stripped TYPE

OFFICIAL DESIGNATION DATE EXAMINED

 Republic of the Philippines
Department of Education
Region V
Schools Division of Camarines Sur
TINAMBAC NORTH DISTRICT
Zone 2,Tamban, Tinambac, Camarines Sur

__________________, 2021

CERTIFICATION
To Whom It May Concern:

This is to certify that MS. JOREZA O. BOTER of Tambang Central School, Tinambac North District as
of today ______________, 2021. Thus, COMPLETE CLEARANCE in this school/district is hereby granted.
Consequently, turnover of property responsibility has been accordingly made to her successor in the
service. (In case of head of property is required). Moreover, the above mentioned person has completely
accounted for all government property received by her during his tenure of service in this school/district.

REY P. BRON BENJAY C. PARON

School Property Custodian School Disbursing Officer

MARITES V. CASTUERA
School Head

DANTE A. ABORDO GIL C. AGRAVANTE

District Property Custodian Public Schools District Supervisor

a. Latest and Complete Address : Tambang, Tinambac, Camarines Sur

b. Amount paid for property losses to school head, school/district property custodian/district
supervisor: None
c. Date of payment: N/A
d. Purpose of clearance: Maternity Leave
e. Other information:

JOREZA O. BOTER
Teacher-I

Address: Zone 2, Tambang, Tinambac, Camarines Sur

Email: gilcatubigagravante
Cellphone No: 09338566360
 CS FORM 41

PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE

I hereby waive all rights and privileges pertaining to professional confidence between
physician and patient, and the physician accomplishing this form is authorized to answer in detail
all questions contained herein.

Signature of Patient

(n.B. Attending physician shall fill in the blanks below. Every detail having been answered to avoid
delay in action on applicant for the above submitted by the patient.)

of the Department of Education, Culture, and Sports

____________________________________
Name of Patient

Having made application for leave of absence on account of illness, I do hereby certify that I will be
the applicant’s actual attending physician from ___________________ to ___________________,
inclusive and from my personal knowledge of the case, the following statements are submitted as
contemplated by the provision of Section 6 of Civil Service Rule XVI.

Name of disease:
Nature of Disease or Disability:

Etiology: Under this heading, in addition to giving fully the etiology of the disease or disability, the
physician must state in the language of the Executive Order or “There are no indications
whatsoever that the disease named was due to viscous or immoral habit” or give the indications.

History:
Description:

A laboratory test __________ made in this case. The applicant was confined to his/her

house/hospital from _________________________ to __________________________, inclusive.

I hereby certify that the above statements was complete and true in every detail and that in
consequence of the disease or disability above specified and the applicant was not well and unable
to be on duty on account of illness from __________________________ to
___________________________ inclusive and that his/her claim is meritorious.

PHYSICIAN’S NAME (Type or Print)

 documentary
stamp

Signature
 CSC Form No. 6 (Revised 1985) APPLICATION FOR LEAVE
Signature: __________________________________ TYPE OF LEAVE
Name: _____________________________________ ( ) VACATION ( ) Within the Philippines
Position:___________________________________ ( ) Abroad ( specify)
Basic Monthly Salary:_________________________ ( ) SICK ( ) Out Patient (specify) _____________
Office/School/District:_________________________ ( ) In Hospital (specify) _____________

Date of Filing: _______________________________ ( ) MATERNITY

No. of working days applied for:_________________ ( ) OTHERS (specify) ________________________
Inclusive Dates: _____________________________
ACTION ON APPLICATION
COMMUTATION:
( ) Requested ( ) Not Requested RECOMMENDING
( ) Approval
FOR PERSONNEL USE ONLY ( ) Disapproved due to _____________________
LEAVE CREDITS As of VL SL TOTAL
GIL C. AGRAVANTE
Less:THIS LEAVE Public Schools District Supervisor
LEAVE BALANCE ( ) APPROVED For ( ) DISAPPROVED DUE

Certified by: _______________ days with pay ________________

_______________ days without pay _____________

GINA A. VALENCIANO MARIA MAGNOLIA F. BRIOSO, CESO VI

Administrative Officer V Assistant Schools Division Superintendent

CSC Form No. 6 (Revised 1985) APPLICATION FOR LEAVE

Signature: __________________________________ TYPE OF LEAVE
Name: _____________________________________ ( ) VACATION ( ) Within the Philippines
Position:___________________________________ ( ) Abroad ( specify)
Basic Monthly Salary:_________________________ ( ) SICK ( ) Out Patient (specify) _____________
Office/School/District:_________________________ ( ) In Hospital (specify) _____________

Date of Filing: _______________________________ ( ) MATERNITY

No. of working days applied for:_________________ ( ) OTHERS (specify) ________________________
Inclusive Dates: _____________________________
ACTION ON APPLICATION
COMMUTATION:
( ) Requested ( ) Not Requested RECOMMENDING
( ) Approval
FOR PERSONNEL USE ONLY ( ) Disapproved due to _____________________
LEAVE CREDITS As of VL SL TOTAL
GIL C. AGRAVANTE
Less:THIS LEAVE Public Schools District Supervisor
LEAVE BALANCE ( ) APPROVED For ( ) DISAPPROVED DUE

Certified by: _______________ days with pay ________________

_______________ days without pay _____________

GINA A. VALENCIANO MARIA MAGNOLIA F. BRIOSO, CESO VI

Administrative Officer V Assistant Schools Division Superintendent