Civil Service Form No.

Revised 2020 ANNEX A

Republic of the Philippines

Department of Education
Division of Davao del Norte

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 __________________________
E.O. No. 292)
Abroad (Specify)
Sick Leave (Sec. 43, Rule XVI, Omnibus Rules Implementing E.O. No. ______________________________ In case of
292) Maternity Leave (R.A. No. 11210 / IRR issued by CSC, DOLE Sick Leave:
and SSS) In Hospital (Specify Illness)
Paternity Leave (R.A. No. 8187 / CSC MC No. 71, s. 1998, as amended) _____________________
Out Patient (Specify Illness) _____________________
Special Privilege Leave (Sec. 21, Rule XVI, Omnibus Rules Implementing
E.O. No. 292) _____________________________________________ In
Solo Parent Leave (RA No. 8972 / CSC MC No. 8, s. 2004) case of Special Leave Benefits for Women:

Study Leave (Sec. 68, Rule XVI, Omnibus Rules Implementing E.O. No. 292) (Specify Illness) ________________________________
_____________________________________________ In
10-Day VAWC Leave (RA No. 9262 / CSC MC No. 15, s. 2005)
case of Study Leave:
Rehabilitation Privilege (Sec. 55, Rule XVI, Omnibus Rules Implementing
E.O. No. 292) Completion of Master's Degree
Special Leave Benefits for Women (RA No. 9710 / CSC MC No. 25, s. 2010) BAR/Board Examination Review

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

Adoption Leave (R.A. No. 8552) Monetization of Leave Credits

Terminal Leave

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
As of _______________________
Vacation Leave
Total Earned
Less this application
7.B RECOMMENDATION
For approval
Sick Leave For disapproval due to
_________________________
___________________________________________
___________________________________________
___________________________________________

Balance
___________________________________________
(Authorized Officer)
(Authorized Officer)
7.C APPROVED FOR: 7.D DISAPPROVED DUE TO:
_______ days with pay _______________________________________
_______ days without pay ___________________________________________ _______ others (Specify)
___________________________________________

REYNALDO B. MELLORIDA, CESO V

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

* 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).