March 2021

1.0000 1.0000
1.0000 1.0000
 1.0000 1.0000

EDWIN A. PALERO, MPA, MHRM

PG Department Head
Provincial Human Resource Management Office

EDWIN I. JUBAHIB
Governor
March 2021

1.0000 1.0000
1.0000 1.0000
 1.0000 1.0000

EDWIN A. PALERO, MPA, MHRM

PG Department Head
Provincial Human Resource Management Office

GALE GUADALUPE G. MORTILLERO, MSLRG, MHRM

PG Assistant Department Head
Provincial Administrator's Office-Administration
March 2021

1.0000 1.0000
1.0000 1.0000
 1.0000 1.0000

ARNEL A. SATOR
Supervising Administrative Offficer
Compensation and Benefits Division
Provincial Human Resource Management Office

ARNEL A. SATOR
Supervising Administrative Offficer
Compensation and Benefits Division
Provincial Human Resource Management Office
March 2021

1.0000 1.0000
1.0000 1.0000
 1.0000 1.0000

EDWIN A. PALERO, MPA, MHRM

PG Department Head
Provincial Human Resource Management Office

EDWIN A. PALERO, MPA, MHRM

PG Department Head
Provincial Human Resource Management Office
Civil Service Form No. 6
Revised 2020

Republic of the Philippines

Provincial Government of Davao del Norte Stamp of Date of Receipt
Government Center, Mankilam, Tagum City, Davao del Norte

APPLICATION FOR LEAVE

1. OFFICE/DEPARTMENT 2. NAME : (Last) (First) (Middle)
PEEDO-DDNHKZ AUZA B.
DONNA

OCT. 11, 2024 NURSE V

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

1 DAY
________________________________________ Not Requested
INCLUSIVE DATES ✘ Requested
OCT. 16, 2024
________________________________________
_______________________________________
(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
DR. JESSIE T. BELGA, FPSMSI, MSPH-HA
(Authorized Officer)

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

_______ days with pay _______________________________________
_______ days without pay ___________________________________________
_______ others (Specify)

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