Maternity Leave - Template For ES and IS

DATA INPUT SHEET ©This template is designed and developed by Michael Benedict L. Emperador.
NOTE: Delete the sample district and school seals and paste your 1.2 × 1.2 inches district and school seals at the center of the space provided for.
District District Seal District Station Code District Address District Email District Contact No. District Web Site
Manticao 009 - Manticao Manticao, Misamis misor.manticao@
Oriental deped.gov.ph
School Full Name School Seal School Station Code (For IS only) School Short Name SchoolAddress School Email School Contact No. School Website
Cabalantian Cabalantian ES Cabalantian, 127798@deped.gov.ph
Elementary School Manticao, Misamis
Oriental
Basic Information Requirements for Maternity Leave

Leave Application Maternity Leave SO for Maternity Leave
Date of Leave Application Indorsement
No. of Days 105 Letter Request
Inclusives Dates from CS Form 6 (Application for Leave)
to CS Form 41 (Medical Certificate for Leave)
Last Name CS Form 7 (Division Clearance)
First Name District Clearance
Middle Name School Clearance
Name Suffix
Appellation Requirements for Reinstatement
Curriculum Level SO for Reinstatement
Services Rendered Indorsement
Letter Request
Position CS Form 211 (Medical Certificate for Reinstatement
Salary Grade Newborn Child's Birth Certificate
Step
Item No.
Employee No.
Basic Monthly Salary
Date of Original Appointment
Date of Birth
Civil Status
Residential Address
Employee Contact No.
School Head JUAN T. DELA CRUZ
School Head Position Head Teacher I
School Treasurer ELLEN L. BALO
School Property Custodian VIRGILIO Q. IBARRAT
Date of Reinstatement Application 04/08/2023
District Supervisor ELCRIS E. CAÑO
School Head Position District In-Charge
District Property Custodian DORWARD BRUCE G. PACANA
NOTE: All documents on this template are set to A4 size paper.
Republic of the Philippines
Department of Education
Region X - Northern Mindanao
SCHOOLS DIVISION OF MISAMIS ORIENTAL
Office of the Schools
Division Superintendent
Date
SPECIAL ORDER FOR MATERNITY LEAVE OF ABSENCE

No.: _____, s. __________
Name of Employee:
Employee No.:
Division Code: 033
Station Code: 009 - Manticao
Services Rendered: 0
Absences: January 0, 1900 to
Experience: 123.77 years
Monthly Basic Salary: ₱ 0.00
105 Days Maternity Leave

Effective January 0, 1900 to
105 Days With Full Pay

Effective January 0, 1900 to
Days without pay
By the Authority of the Secretary of Education
APPROVED:
Address: Del Pilar corner Velez St., Barangay 29, Cagayan de Oro City
Telephone No.: (088) 881-3094 ½ Text: 0917-8992245 (Globe)
Website: www.deped.misor.net
Email: misamis.oriental@deped.gov.ph
Schools Division of Misamis Oriental
DISTRICT OF MANTICAO
Office of the Public Schools
District Supervisor
1st INDORSEMENT
January 0, 1900
Respectfully forwarded to the Schools Division Superintendent of Misamis

Oriental, Cagayan de Oro City, the herein Pertinent Papers for Maternity Leave
of , of Cabalantian Elementary School, effective January 0, 1900 to ,
recommending approval.
ELCRIS E. CAÑO
District In-Charge
Address: Manticao, Misamis Oriental

Email: misor.manticao@deped.gov.ph
District of Manticao
CABALANTIAN ELEMENTARY SCHOOL
THE SCHOOLS DIVISION SUPERINTENDENT

Division of Misamis Oriental
Don A. Velez St., Cagayan de Oro City
Thru Channel
Sir,
I have the honor to apply for a 105-day Maternity Leave effective January 0, 1900 to . Please
see the attached pertinent papers for my maternity leave for your perusal.
I am hoping for your favorable action and approval on my maternity leave.
Very respectfully yours,
0
Mobile No.: _________________
Item No.: OSEC-DECSB-________-____
Noted by:
JUAN T. DELA CRUZ

Head Teacher I
Address: Cabalantian, Manticao, Misamis Oriental

Email Add.: 127798@deped.gov.ph
Civil Service Form 6
Revised 2020 ANNEX A
Don Apolinar Velez St., Cagayan de Oro City
___________________
Date Received
APPLICATION FOR LEAVE
1. OFFICE/DEPARTMENT 2. NAME: (Last) (First) (Middle)
Cabalantian ES, Manticao District
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)
ü 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.8, s.2004) In Hospital (Specify Illness)
Special Privilege Leave (Sec. 25, Rule XVI, Omnibus Rules Implementing E.O. No.292) Out Patient (Specify Illness)
Solo Parent Leave (R.A. 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 (R.A. 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 (R.A. 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

105 days 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
JUAN T. DELA CRUZ

Head Teacher I
ERLINDA G. DAEL, PhD, CESE

Authorized Officer Assistant Schools Division Superintendent
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:

days with pay
days without pay
others (Specify)
JONATHAN S. DELA PEÑA, PhD, CESO V

Schools Division Superintendent
CS Form No. 41
CIVIL SERVICE COMMISSION
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.
Applicant
(NB: Attending Physician should fill in the blanks below. Every detail should be answered to avoid delay in action on
Application for Leave submitted by Patient.)
#VALUE!
Name of disease or disability:
Nature of disease or disability:
ETIOLOGY: (Under this heading, in addition to giving fully the etiology of the disease or disability, the physician must either
state in the language of the Executive Order, "There are no indications whatsoever that the disease named was
due to immoral or vicious habits", or give the indications.)
HISTORY:
DESCRIPTION:
A laboratory test or examination was made in this case: ____________________________________________
#VALUE!
#VALUE!
Name and Signature of Physician

Documentary
License No.:
Stamp
Address:
Date of Issue:
CS Form No. 7
Revised 2018

(Instructions at the back)
I PURPOSE: MATERNITY LEAVE/VACATION (PERSONAL) LEAVE/SPECIAL LEAVE/TRANSFER (WITHIN THE DIVISION)
January 0, 1900
Date of Application
TO: DIVISION OF MISAMIS ORIENTAL
I hereby apply fpr clearance from money, property and worl-related accountabilities for:
Purpose: Transfer Resignation Other Mode of Separation:
Retirement ü Leave Please specify: MATERNITY LEAVE
Effectivity/Inclusive Period: January 0, 1900 to
Offie Assignment: Cabalantian ES
District/Address: Manticao District
Position/SG/Step: Name and Signature of Employee
II CLEARANCE FROM WORK-RELATED ACCOUNTABILITIES
I hereby certify that this applicant is cleared of work-related accountabilities from this Unit/Office/Dept.
JUAN T. DELA CRUZ

School Head
III CLEARANCE FROM MONEY AND PROPERTY ACCOUNTABILITIES
Not
Name of Unit/Office/Department Cleared Name of Clearing Officer/Official Signature
Cleared
1. Administrative Sector
a. Supply and Property Procurement and Management Services: ELEONOR P. CRUZ
As to supply and property procurement responsibility AO IV - Supply Officer
b. Personnel and Payroll Section: MELANIE C. ESTENZO
As to human resource welfare and assistance services AO IV - Supply Officer
c. MODOECCO Office: MILA A. JANUBAS
As to Agency-accredited Union/Cooperative Agriculturist II - MODOECCO Officer
2. Administrative/Records
a. Records Section: NIÑOJOMAR S. CABLAY
As to filing of SALN, 201 files/records borrowed AO IV - Records Officer
b. Office of the Administrative Officer V: RHODORA LANZA-GALLARES
As to Administrative Services OIC, AO V - Administrative Division
3. Finance and Assets Management
a. Cashiering Section: MARRISA FAY S. JADAP
As to Cash Accountability AO IV - Cashier
b. Office of the Budget Officer: MARK LORREN T. TEJANO
As to Budget Accountability and Provident Fund AO V - Budget Officer
c. Office of the Accountant: ELMAR G. ANOC, CPA
As to Cash Advcances and Overpayment Accountant III
4. Professional and Institutional Development
a. Human Resource Development IRISH KARYLLE D. MONTE, PhD
As to Training and Development Services Senior Education Program Specialist
IV CERTIFICATION OF NO PENDING ADMINISTRATIVE CASE
a. Internal Affairs Office/Legal Affairs Office: Atty. CHRISTOPHER F. PASCO, CPA
As to Training and Development Services Attorney III
with pending administrative case
with ongoing investigation (no formal charge yet)
V CERTIFICATION
I hereby certify that this employee is cleared of work-related, money and property accountabilities from this agency. This certification
includes no pending administrative case from this agency.
JONATHAN S. DELA PEÑA, PhD, CESO V

Schools Division Superintendent
Page 1 of 2

District Supervisor
DISTRICT CLEARANCE
To Whom It May Concern:
THIS IS TO CERTIFY that according to the records filed in this office, , of

Cabalantian Elementary School, is properly cleared of money and property
accountabilities effective January 0, 1900.
This clearance is issued to the above-named employee on January 0, 1900 in

Manticao, Misamis Oriental for the purpose of Maternity Leave effective January 0,
1900 to .
DORWARD BRUCE G. PACANA

District Property Custodian
ELCRIS E. CAÑO
District In-Charge

SCHOOL CLEARANCE
To Whom It May Concern:
THIS IS TO CERTIFY that according to the records filed in our school,

, , is properly cleared of money and property accountabilities effective
January 0, 1900.
This clearance is issued to the above-named employee in connection

to her Maternity Leave effective January 0, 1900 to .
This clearance is issued on in Cabalantian, Manticao, Misamis

Oriental.
ELLEN L. BALO VIRGILIO Q. IBARRAT

School Treasurer School Property Custodian
JUAN T. DELA CRUZ

Head Teacher I

CERTIFICATION
THIS IS TO CERTIFY that the class/teaching load of , , who is applying for Maternity
Leave effective January 0, 1900 to , shall be handled by the teacher/s whose name/s and
signature/s are reflected below.
This certification is issued on in Cabalantian, Manticao, Misamis Oriental.
JUAN T. DELA CRUZ

Head Teacher I
NAME/S OF TEACHER/S WHO SHALL HANDLE THE CLASS/TEACHING LOAD

OF ON THE DURATION OF HER MATERNITY LEAVE
EFFECTIVE JANUARY 0, 1900 TO
SUBJECT NAME TEACHER SIGNATURE OF TEACHER

EsP (Grade 4) Ronnah Marie V. Flores
Math (Grade 4) Liwelyn C. Sotto
Filipino (Grade 4) Ronnah Marie V. Flores
EPP (Grade 4) Ronnah Marie V. Flores
MAPEH (Grade 4) Ronnah Marie V. Flores
Prepared by: Noted by:
JUAN T. DELA CRUZ ELCRIS E. CAÑO

Head Teacher I District In-Charge

PERTINENT PAPERS
FOR MATERNITY LEAVE
Effectivity: January 0, 1900 to (105 days)
Item Number: OSEC-DECSB-________-____
Assigned Station: Cabalantian Elementary School
Submitted by:
0.00
Contact No.: ___________________
DIVISION OF MISAMIS ORIENTAL
Cagayan de Oro City
Revised Plotting Form for Substitute Position
____________________ Level
For School Year 1899 - 1900
Name of School: CABALANTIAN ELEMENTARY SCHOOL

Name of District: MANTICAO
Name of Area of
Item No. Inclusive Inclusive Division Station
Employee/Indicate Position Name of Replacement Address Concentration / Station To Remarks
OSEC-DECSB- Dates Dates Rank From
VL/SL/ML/Promoted Major Field
, 0 0.00 12/30/99 YURONG, ISABEL O. Purok 2-A 12/30/99 Cabalantian ES

to Pagawan, to
Mobile No.: 0950-006-0726 Manticao,
Maternity Leave Email: Mis. Or.
105 days isabel.yurong96@gmail.com
Important: All data required on this form should be filled up properly.

Attach Ranklist. Plotting shall be returned due to unfilled data and ranklist.
This is to certify that the data above has been verified and are found true and correct.
Justification:
Checked Against Ranklist: APPROVED:
JUAN T. DELA CRUZ MARIO T. ARROYO JONATHAN S. DELA PEÑA, PhD, CESO V
Head Teacher I Personnel Officer Designate Schools Division Superintendent
PLOTTING FORM FOR

SUBSTITUTE POSITION
(MATERNITY LEAVE)
Vice:
Effectivity: January 0, 1900 to
Assigned Station: Cabalantian Elementary School
Submitted by:
ELCRIS E. CAÑO
District In-Charge
Office of the Schools
Division Superintendent
Date
SPECIAL ORDER FOR REINSTATEMENT TO DUTY

No.: _____, s. __________
Name of Employee:
Division Code: 033 Station Code: 009 - Manticao
Employee No.: 0 Monthly Basic Salary: ₱ 0.00
Nature of Leave: Maternity Leave
Services Rendered: 0
Effectivity Date: January 0, 1900 to
Reinstatement Date: #VALUE!
By the Authority of the Secretary of Education
APPROVED:
Address: Del Pilar corner Velez St., Barangay 29, Cagayan de Oro City
Telephone No.: (088) 881-3094 ½ Text: 0917-8992245 (Globe)
Website: www.deped.misor.net
Email: misamis.oriental@deped.gov.ph
District Supervisor
1st INDORSEMENT
April 8, 2023
#VALUE!
ELCRIS E. CAÑO
District In-Charge

April 8, 2023
THE SCHOOLS DIVISION SUPERINTENDENT

Division of Misamis Oriental
Don A. Velez St., Cagayan de Oro City
Thru Channel
Sir,
#VALUE!
Very respectfully yours,
Position
Mobile No.: _________________
Item No.: OSEC-DECSB-________-____
Noted by:
JUAN T. DELA CRUZ

Head Teacher I

CS Form No. 211
Revised 2018
MEDICAL CERTIFICATE
(For Reinstatement)
INSTRUCTIONS
1. This medical certificate should be accomplished by a licensed government physician.
2. Attach this certificate to original appointments and reinstatements.
3. The results of the following pre-employment medical/physical/psychological tests
must be attached to this form (if applicable):
Blood Test
Urinalysis
Chest X-Ray
Drug Test
Psychological Test
Neuro-Psychiatric Examination
FOR THE PROPOSED APPOINTEE

NAME (Last Name, First Name, Name Extension (if any) and Middle Name) AGENCY / ADDRESS
Don Apolinar Velez St.,
, Cagayan de Oro City
ADDRESS
AGE SEX CIVIL STATUS POSITION
123 years Female
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 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

PERTINENT PAPERS FOR

REINSTATEMENT TO DUTY
(On Maternity Leave effective January 0, 1900 to (105 days)
Reinstatement Date: ###

School: Cabalantian Elementary School
Submitted by:
0.00
Contact No.: ___________________

Maternity Leave - Template For ES and IS

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Maternity Leave - Template For ES and IS

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DATA INPUT SHEET ©This template is designed and developed by Michael Benedict L. Emperador.

Basic Information Requirements for Maternity Leave

SPECIAL ORDER FOR MATERNITY LEAVE OF ABSENCE

Division Code: 033

Station Code: 009 - Manticao

Absences: January 0, 1900 to

Experience: 123.77 years

Monthly Basic Salary: ₱ 0.00

105 Days Maternity Leave

105 Days With Full Pay

Days without pay

By the Authority of the Secretary of Education

Respectfully forwarded to the Schools Division Superintendent of Misamis

Address: Manticao, Misamis Oriental

THE SCHOOLS DIVISION SUPERINTENDENT

I am hoping for your favorable action and approval on my maternity leave.

Very respectfully yours,

JUAN T. DELA CRUZ

Address: Cabalantian, Manticao, Misamis Oriental

3. DATE OF FILING: 4. POSITION: 5. SALARY:

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

7. DETAILS OF ACTION ON APPLICATION

JUAN T. DELA CRUZ

ERLINDA G. DAEL, PhD, CESE

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

JONATHAN S. DELA PEÑA, PhD, CESO V

Name of disease or disability:

Nature of disease or disability:

A laboratory test or examination was made in this case: ____________________________________________

Name and Signature of Physician

Republic of the Philippines

JUAN T. DELA CRUZ

JONATHAN S. DELA PEÑA, PhD, CESO V

Office of the Public Schools

To Whom It May Concern:

THIS IS TO CERTIFY that according to the records filed in this office, , of

This clearance is issued to the above-named employee on January 0, 1900 in

DORWARD BRUCE G. PACANA

Address: Manticao, Misamis Oriental

To Whom It May Concern:

THIS IS TO CERTIFY that according to the records filed in our school,

This clearance is issued to the above-named employee in connection

This clearance is issued on in Cabalantian, Manticao, Misamis

ELLEN L. BALO VIRGILIO Q. IBARRAT

JUAN T. DELA CRUZ

Address: Cabalantian, Manticao, Misamis Oriental

This certification is issued on in Cabalantian, Manticao, Misamis Oriental.

JUAN T. DELA CRUZ

NAME/S OF TEACHER/S WHO SHALL HANDLE THE CLASS/TEACHING LOAD

SUBJECT NAME TEACHER SIGNATURE OF TEACHER

Prepared by: Noted by:

JUAN T. DELA CRUZ ELCRIS E. CAÑO

Address: Cabalantian, Manticao, Misamis Oriental

Name of School: CABALANTIAN ELEMENTARY SCHOOL

, 0 0.00 12/30/99 YURONG, ISABEL O. Purok 2-A 12/30/99 Cabalantian ES

Important: All data required on this form should be filled up properly.

Checked Against Ranklist: APPROVED:

PLOTTING FORM FOR

SPECIAL ORDER FOR REINSTATEMENT TO DUTY

Division Code: 033 Station Code: 009 - Manticao

Employee No.: 0 Monthly Basic Salary: ₱ 0.00

Nature of Leave: Maternity Leave

Effectivity Date: January 0, 1900 to