Civil Service Form No.

6
Revised 2020

Stamp of Date of Receipt

Republic of the Philippines
Caraga State University Cabadbaran Campus
Cabadbaran City, Agusan 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

In case of Vacation/Special Privilege Leave:
Vacation Leave (Sec. 51, Rule XVI, Omnibus Rules Implementing E.O. No. 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. 292)
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 (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

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

ROXAN M. ILUSTRISIMO
Admin Officer IV (Authorized Officer)

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

days with pay

days without pay
others (Specify)

ROWENA P. VARELA, Ph.D.

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

*For leave of absence for thirsty (30) calendar days or more 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).