LEAVE APPLICATION FORM

PART I – TO BE FILLED OUT BY THE EMPLOYEE

NAME (LAST NAME) (FIRST NAME) (M.I.) EMP. NUMBER

POSITION DEPARTMENT CODE DATE FILED (MM/DD/YYYY)

LEAVE TYPE

☐ SL – SICK LEAVE ☐ AH – AUTHORIZED HALF-DAY ☐ VAWCL – VIOLENCE AGAINST

☐ VL – VACATION LEAVE
☐ EL – EMERGENCY LEAVE
☐ AA – LEAVE WITHOUT PAY
☐ AU – AUTHORIZED UNDERTIME
☐ ML – MATERNITY LEAVE (RA 11210)
☐ PL – PATERNITY LEAVE (RA 8187)
☐ SPL – SOLO PARENT LEAVE (RA 8972)
☐ SLW – SPECIAL LEAVE FOR WOMEN
(RA 9710)
WOMEN SPECIAL LEAVE (RA 9262)
☐ ALLOCATED MATERNITY LEAVE
CREDITS (RA 11210)
☐ OTHERS

NUMBER OF DAYS: ___________________________________ DATE(S) APPLIED FOR: ________________________________

REASON(S) FOR FILING LEAVE (PLEASE ATTACH REQUIRED DOCUMENTS IF NECESSARY)

PART II – TO BE FILLED BY AUTHORIZED PERSONNEL ONLY

CLINIC ASSESSMENT (FOR EMPLOYEES WHO WENT ON A SICK LEAVE ONLY) DATE OF ASSESSMENT
(MM/DD/YYYY)

TIME OF ASSESSMENT
(FROM-TO)

ASSESSED BY
NAME

LICENSE NO.

☐ FIT TO WORK ☐ FOR MEDICATION ☐ UNFIT TO WORK SIGNATURE

RECOMMENDING APPROVAL DEPARTMENT HEAD’S APPROVAL

☐ APPROVED ☐ APPROVED
☐ DISAPPROVED ☐ DISAPPROVED

REMARKS: REMARKS:
_____________________________________________________ _____________________________________________________

_____________________________________________________ _____________________________________________________

_____________________________________________________ _____________________________________________________

Name/Signature Date Name/Signature Date

CUT THIS PORTION UPON SIGNING OF THE DEPARTMENT HEAD

NAME (LAST NAME) (FIRST NAME) EMP.
(M.I.) NUMBER

POSITION DEPARTMENT CODE DATE FILED (MM/DD/YYYY)

RECOMMENDING APPROVAL DEPARTMENT HEAD’S APPROVAL

☐ APPROVED ☐ APPROVED
☐ DISAPPROVED ☐ DISAPPROVED

Name/Signature Date Name/Signature Date

Document Code: DDC-F-F-009.0 Effective Date: 16MAY2016

Page 1 of 1 Latest Review Date: 03JUL2018