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Leave Application Form: Date Filed (Mm/Dd/Yyyy)

This document is a leave application form with two parts. Part I is filled out by the employee and includes their personal information, the type of leave being requested, the number of days, and reason for leave. Part II is for authorized personnel and includes a clinic assessment if the leave is for sickness. It also includes areas for recommending approval or disapproval of the leave request and signatures of the recommending approver and department head.

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William Leo Gascon
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151 views1 page

Leave Application Form: Date Filed (Mm/Dd/Yyyy)

This document is a leave application form with two parts. Part I is filled out by the employee and includes their personal information, the type of leave being requested, the number of days, and reason for leave. Part II is for authorized personnel and includes a clinic assessment if the leave is for sickness. It also includes areas for recommending approval or disapproval of the leave request and signatures of the recommending approver and department head.

Uploaded by

William Leo Gascon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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

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

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