Ch Sn rm No 6 sprtsed 920 ANNEX A Republic ofthe Phitippines & Philippine Charity Swoopstakes Office ‘un Plaza Bullding, 1607 rincston Steet comer Shaw Bouioverd, 7) oe mantener APPLICATION FOR LEAVE [OF RGEDEPARTNENT @ NAMED lesb ap vay 13. DATE OF FILING 4, POSITION 5. SALARY 6, DETAILS OF APPLICATION [6.8 TYPE OF LEAVE TO BE AVAILED OF D1 Vacation Leave (ss, ects Rk nomi 0, No 22) Cl Mandatory’Forced Leavers 25, Rue On ie Ilomiing 0. Na 22) Ti Sick Leave (se. alex Onntu Res mpanerieg £0, No.2) Cl Maternity Leave je. No. 11210) tems Wy C5C, LE a5) i Peterity Leave is N87 /¢80 Me Ne 7,5. 198 a ane) special Priviege Leave (xe 2, fle 4, Ome Rss nperanting £0. Ma 20) Solo Parent Leave avo. 09721 50M 8.5204) 7 stuay Leave (ax 68 rs x Om le rpg £0.22) 1 10-Day VAWC Leave mano 52/69: No 15,5208) Gi Rehabitation Priviege (se: ue x Os Rus ingen 0 No. 22) Li Special Leave Benefis for Women fe No 9710/630 Hea 25 5201) i Special Emergency (Calamity) Leave (SCN Ns 2. 2012s aneriet) C1 Adoption Leaver no 1559 Others: a= [6.8 DETAILS OF LEAVE In case of Vacation/Special Privilege Leave: within the Phiippines Di Abroad (Speci), In case of Sick Leave: Ditn Hosptat (Speci tiness) ToutPatient (Specify ness) In caso of Special Leave Benefits for Women: (Specity ness) In case of Study Leave: Completion of Master's Degree Cl BARVBoard Examination Review ther purpose: Cl Monetization of Leave Credits Cl Terminal Leave [6.¢ NUMBER OF WORKING DAYS APPLIED FOR INCLUSIVE DATES le.D COMMUTATION CI Not Requested Ci Requested 17.A CERTIFICATION OF LEAVE CREDITS. Aso: ‘Vacation Leave | Sick Leave Total Earned Tess tis ‘Balance, ‘Gignature of Appian) 7. DETAILS OF ACTION ON APPLICATION }7.8 RECOMMENDATION For approval For disapproval due to Thuorizea OTcery 7. APPROVED FOR: days with pay days without pay others ‘specty) (Authorized Officer) | 7.D_ DISAPPROVED DUE TO: (Authorized Offical)INSTRUCTIONS AND REQUIREMENTS ‘Application for any type of lave shall be made on this Form and to be 2 hed at least in ‘wih documentary requirements, 28 folows: 4. Vacation eave" It shal be fied jve (6) cays in advance, whenever possible, of he cele date of sucn leave. Vacation leave within n the Philppins or ‘abroad shall be indicated inthe form for purposes of securing travel uhory and competing clearance. from money and work ‘accountablies. 2, MandatoryfForced leave ‘Annual five-day vacation leave shal be free i not taken during the year. In case tho scheduled leave has been cancelled inthe exigency Othe service by the head of agency, shall na longer be deducted rom the accumulated vacation leave. Avaliment of one (1) day or mora Vacation Leave (VL) shall be considered for complying the ‘mandatoryforved leave subject othe conditions under Secton 25, Rule XV of the Omntus Rules implementing E.O. No, 292. 3. Sick leavet * It shal be fied immediately upon employee's return from such ave «I ed in advance or exceeding fve (5) days, application shal be ‘accompanied by a merical cereale in case mecical consultation was not availed of, an affidavit should be executed by an epokcant. 4. Maternity leave - 105 days + Proof of pregnancy eg. ultrasound, doctors certicale on the ‘expoctd date of delivery + Accomaished Notice of Alocaion of Mateity Leave Credits (CS Form No. 6a), needed ' Seconded female employees stall enjoy maternity leave wih fl pay inthe recipient agency. 5. Paternity nave ~7 days Proot of chid's delvry 0.9. bith centfcate, medical cartficate and mariage contract 8 Special Priviloge leave -3 days It shall be fld/aporoved fora least ore (1) Wook pir to avainent, fexcopt on emergency cases. Special prvlego leave within the PPuippines or abroza shall be inciated inthe tom for purposes of secuting travel authorly and completing clearance from money and work accountabilities. 7. Solo Parant leave 7 days It shal be fled in advance or whonevar possible ve (5) days before going on such eave with updated Sol Parent identitcaton Card 8. ‘Study leave" - up to 6 months. * Shall meet the agency's intemal requirements, any, * Contract between te agency head or authorized represantaive and the employee concomed, 8. VAWC leave 10 days ‘© It shall be fled in advance or immesiatoly upon the women ‘employee's retur rom such leave, «= Itstallbe accompanied by any fe folowing supporting documents: 4, Barangay Protection Order (BPO) obtained fom the barangay; », Temporary/Permanent Protection Order (TPOVPPO) obtained fiom the cout ¢. ifthe protection orders not ytissued by the barangay ortho cour, 4 ceriicaion issued by the Punong BarangayiKagawad ot Prosecutor or the Cierk of Cout hat the applicabon forthe BPO, TPO or PPO has been fied wih the said offce sell be sufcent ‘0 suppor the application for he ten-day leave; or 4. in he absence ofthe BPO/TPOIPPO or the certiction, a police ‘eport specifying the deta of the accurtence of violence on the Wielm and a medical certicate may be considered, al the lscreton of the immediate supervisor of the wean employee concemed. 10. Rehabilitation eave’ ~ up to 6 months ‘+ Apicaion shat be made within one (1) week from the time of the accident except when a longer period is warated, * Leter request supported by relevant reports such as the police report ary, ‘= Medical cerifeale on the nature of the injuries, the course of ‘reatment involved, andthe need to undergo rst, recuperation, and fehaoitavon, asthe case may be ‘Wren concurrence ofa government physician shouldbe obtained Felative to the recommendation for renablitaton the atending piysician is a private practioner, parieuely onthe duration ofthe etad of rehabitato. ‘1. Special leave benefits for women* —up to 2 months ' The application may be tied n advance, thal, a east vo (5) days ‘orto the scheduled dae of the gynecological surgery that willbe undergone by the employee. in case of emergency, the application {or special leave shel be fled immediately upon employee's return ‘but during confinement the agency shal be notfied of sed surgery * The application shall be accompanied by @ medical cartiicat filed ‘out by the proper medical auhoctas, @. the atlncing surgeon accompanied by a cinical summary veflecing the gynecoiogical ‘soccer which shall be addressed or was addressed by the said surgery; the histopathologicalrepert the operative tecigue used for the surgory the duration of the surgery inuding the peri ‘operative period (pero of confinement around surgery), 38 wel 3s the employees esimaied period of recuperation forthe Same 412. Special Emergency (Calamity) leave up 10 5 days ‘= The special emergency leave can be applied fr a maxinum of five (5) svaight working days o staggered basis within tity (20) days from the actual occurence of the natural calamitysisaster, Said Drivlege shall be enjoyed once a year, notin every instance of Calamity or disaster, ‘The head of fice shal take full esponsiity for he grant of special ‘emergency leave end veiication of the employee's eligbily to be ‘tanied thereof. Said veficaen shal include: validation of place of Tesidence based on latest avalable records of the affected ‘employee; verfcation that the place of residence is covered inthe declaration of calamty area by the proper government agency, and such other prools as may be necessary 18. Monetization of leave credits ‘Appicaton for monetizaton of tity percent (50%) ot more of the ‘accuimiated leave creis shall be accompanied by later request 10 the head ofthe agency stating he vai and usable reasons, 14 Terminal leave" Froof of employee's resignation or rerement or separation from the 18. Adoption Leave ‘Application for adoption leave shall be fled with an authenticated copy of the Pre-Adoptive Placomant Authoriy isoued by the DDepariment of Social Welfare and Development (DSWD). For eave of absence fr tity (30) calendar day or more and ermal eave, application sal be accompanied bya clarance fom money, propaty and workelated accounlabies (ursvant to CSC Memorandum Circular No, 2, . 1985).