Leave Forms

. Form No. 6 Revised 1994

APPLICATION FOR LEAVE 1. OFFICE/AGENCY Department of Education

2. NAME

3. DATE OF FILING

4. POSITION

6. (a) TYPE OF LEAVE

6.

(Last)

] Vacation ] Transact Employment ] Others (Specify)

[ [ [

] Sick ] Maternity ] Others (Specify)

(Middle)

5. SALARY (Monthly)

6.

[ [ [

(First)

Employee No: (c) WHERE LEAVE WILL BE SPENT IN CASE OF VACATION LEAVE [ [

6.

(b) NUMBER OF WORKING DAYS APPLIED FOR _____________ Inclusive Dates ________________ ________________

] Within the Philippines ] Abroad (Specify) ______________________ ______________________ ______________________ (d) COMMUTATION

[

] Requested

[

] Not Requested

___________________________ (Signature of Applicant)

DETAILS OF ACTION OF APPLICATION 7. (a) CERTIFICATION OF LEAVE CREDITS as of ___________________

Vacation

Sick

Total

Days

Days

Days

7.

(b) RECOMMENDATION [

] Approved

[

] Disapproved due to __________________ __________________

____________________________ (Authorized Official)

RENZ ROY A. RAMOS, A.O. IV (Authorized Official)

7.

(c) APPROVED FOR _________ Days with pay _________ Days without pay _________ Others

7. (d) DISAPPROVED DUE TO __________________________________________ __________________________________________ __________________________________________

NATIVIDAD P. BAYUBAY, CESO VI Schools Division Superintendent (Authorized Official) Note: 1. 2. 3.

Application for Vacation of Sick Leave for one (1) full day or more shall be in this form. Application for Vacation Leave filed in advance or whenever possible, five (5) days before going on such leave. Application for Sick Leave filed in advance or exceeding five (5) days shall be accompanied by a medical certificate with documentary stamp issued by a Government Physician and their License Number should be clearly indicated.

Republic of the Philippines Department of Education Region IX, Zamboanga Peninsula Division of ZamboangaSibugay FIELD OFFICE OF KABASALAN -------------------The Schools Division Superintendent Division of ZamboangaSibugay Ipil, ZamboangaSibugay Sir/Madame: I have the honor to request that my absences ________________________________ (In figure) ___________________________________ Days from _____________ 20____ to ___________ 20____ be offset from my vacation service credits. Enclosed are Civil Service Form # 6 (Application for Leave) and Civil Service Form # 41 (Medical Certificate).

RECOMMENDING APPROVAL:

_____________________________ Principal/Head Teacher

Very truly yours,

______________________________ (Signature over Printed Name)

1stIndorsement Field Office of Kabasalan

Respectfully forwarded to the Division Superintendent of Schools, Zamboanga Sibugay, Ipil, Zamboanga Sibugay, recommending approval on the request of _________________________________ who has earned vacation service credits as per Division Administrative Order (DAO) no. _______________ series ______________.

___________________________ School Head

MEDICAL CERTIFICATE I HEREBY waive my right and privileges pertaining to professional confidence between physician and patient and the physician accomplishing this form are authorized to answer on detail all questions contained herein. ________________________ Name of Patient (N.B) Attending physician should fill in the blank below. Every detail should be answered to avoid in action application for leave submitted by the patient. _____________________________ of the DEPARTMENT OF EDUCATION having made application for leave of absence on account of illness. I do hereby certify that I was the applicant’s attending physician from __________________ to _________________ inclusive and from my professional knowledge of the case the following statements are submitted by the provision of Section 7 of the Civil Service Rule XVL. Name of the Disease or Disability _____________________________________________________________________________________________ Nature of the Disease or Disability _____________________________________________________________________________________________ ETIOLOGY: Under this heading, in addition for giving fully the Etiology of the disease or disability, the physician must either state in the language of Executive Order. There are no indications whether that the disease named was due to immoral or vicious habit or give the indication. _____________________________________________________________________________________________ History: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Description: _____________________________________________________________________________________________ _____________________________________________________________________________________________ A laboratory test/examination was ______________________ made in this case. The applicant was confined to his/her house/hospital from ________________________ to ________________________ inclusive. I HEREBY CERTIFY that the above statement are complete and true in every detail and that in absence of the disease or disability above specified applicant was ill/unable to be on duty on account of illness from ______________________ to ___________________inclusive and that his/her claim is meritorious. Signature ___________________________ Designation _________________________ Address ____________________________

Documentary Stamp

Date: _____________________________

Republic of the Philippines Department of Education Region IX, Zamboanga Peninsula Division of ZamboangaSibugay DISTRICT OF KABASALAN Date: ______________________ The Schools Division Superintendent Division of ZamboangaSibugay Ipil, ZamboangaSibugay Madam: I have the honor to apply for reinstatement from ______________ Leave of Absence effective ______________, 20 ___. I was on _______________ leave for the period from _____________, 20 ____ to ______________, 20 ___. This office on __________________ , 20 ____ approved this leave. Forms or pertinent papers marked X below are herewith submitted as required. ______________ Original Copy of Birth Certificate of my child ______________ Medical Certificate with documentary stamp duly accomplished by government physician certifying that I am now fit to return to teach/work ______________ Transcript of Official Record date _________, 20 ___ , is from the study leave of absence______________ Special Order of Graduation from study leave The following data are also furnished for the information of the office: 1. 2. 3. 4. 5.

My leave was for the period from ________________, 20 ____ to __________________, 20 ____. I delivered on __________________ , 20____. That I extended my leave from __________________, 20____ to ___________________, 20____. Number of days service credits used to be offset this leave was _________. The last balances of my service credits after deductions from the same from this leave will be _____ days. 6. Name of substitute to be dropped ___________________________________.

Very truly yours,

__________________________________ Signature of teacher/employee Present Salary per annum ___________ Div. Code: 144 Sta. Code: 006 Employee Number ________________ 1stIndorsement District of Kabasalan Respectfully forwarded to the Division Superintendent of Schools, Division of ZamboangaSibugay, Ipil, ZamboangaSibugay, recommending approval of the reinstatement of Mr/Mrs _____________________________Effective ____________________, 20 ____.

__________________________ District Supervisor

Republic of the Philippines Department of Education Region IX, Zamboanga Peninsula Division of ZamboangaSibugay FIELD OFFICE OF KABASALAN

July 19, 2018 NATIVIDAD P. BAYUBAY, CESO VI Schools Division Superintendent Division of ZamboangaSibugay Ipil, ZamboangaSibugay MADAM: I have the honor to recommend Ms.Eleonor E. Montecalvo, Provisional Substitute Teacher vice Mrs. Josephine G. Tayros regular teacher of Lacnapan Elementary School, this district who is on Sick Leave of Absence effective July 18, 2018 to August 16, 2018. Here is some information of the recommended: Inclusive period of service: School Assignment: Civil Service Eligibility: Place Taken: 1. Highest Educational Attainment: Year Graduated: Latest Performance Rating: 2. Employee No: 3. Taxpayer’s Identification No: 4. Date of Birth: 5. Place of Birth : 6. Previous Appointment of the School Year: 7. Reasons for recommending this applicant:

July 18 , 2018 to August 16, 2018 Lacnapan Elementary School Licensure Examination for Teachers (LET) Pagadian City Bachelor in Elementary Education 2017 None None Applied February 22, 1994 Labuagon, Kibawe, Bukidnon None Eligible to handle the position.

Very truly yours,

EVANGELINE B. APARICE SCHOOL HEAD

APPROVED: NATIVIDAD P. BAYUBAY, CESO VI Schools Division Superintendent

Republic of the Philippines Department of Education Region IX, Zamboanga Peninsula Division of ZamboangaSibugay DISTRICT OF KABASALAN

July 6, 2018

The Schools Division Superintendent Division of ZamboangaSibugay Ipil, ZamboangaSibugay MADAM: I have the honor to submit herewith the following to wit;

1. Application for Leave of Absence of the following teachers: a. Francel S. Mangangot b. Amelinda R. Gumandao c. Sonia V. Cervantes d. Josephine P. Natividad e. Criselda R. Simbol f. Fernando M. Bucan 2. Monthly Payroll Worksheet and Report of Service for the month of June 2018. 3. Proportional vacation Pay Computation of Goodyear PS

Please acknowledge receipt hereof.

Very truly yours,

EVELYN A. MANCERA Principal