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Leave of Absence Application Form

Aubrey R. Gumatay has applied for a one day vacation leave from September 29, 2023. All leave applications must be approved by the department head in advance. Sick leave applications require a medical certificate for absences over two days. Gumatay's application will be reviewed by human resources and the MHSS physician to confirm the illness before the department head makes a decision on whether to approve the requested leave.

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126 views1 page

Leave of Absence Application Form

Aubrey R. Gumatay has applied for a one day vacation leave from September 29, 2023. All leave applications must be approved by the department head in advance. Sick leave applications require a medical certificate for absences over two days. Gumatay's application will be reviewed by human resources and the MHSS physician to confirm the illness before the department head makes a decision on whether to approve the requested leave.

Uploaded by

argumatay
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

Document No.

: FM-2-ADM-2017-001
ADMINISTRATIVE OFFICE
Effective Date: July 5, 2017
APPLICATION FOR LEAVE OF ABSENCE

Aubrey R. Gumatay
NAME:
Office of the Registrar
DEPARTMENT:
DATE FILED: September 22, 2023
Employee No: 2305001

1. All leave must have the prior approval of the Department Head concerned and maybe re-schedule to another date if necessary.
2. All applications for vacation leaves must be filed before the actual date of absence.
3. Sick leave application must be field immediately upon return to work. In excess of two (2) days, application for leave of absence should be
supported by a MEDICAL CERTIFICATE.
4. All application for leave of absence must be field in duplicate copies.
TO BE FILLED BY EMPLOYEE

Type Vacation Leave


Of Leave Sick Leave No. of Days From: September 29, 2023
Birthday Leave Applied
Maternity Leave
1 Day September 29, 2023
Paternity Leave To:
/ Others (special leave)

Reason FOR SICK LEAVE: Employee’s Signature:


For OPD Schedule Nature of Illness: ______________
Leave Place of Confinement: ______________
Date first notified MHSS Physician: ______________
TO BE FILLED BY HRD DEPARTMENT

Leave Credits Available:


Less Applied Leave:
Less Balance:
As of Date:

Certified by:

TO BE FILLED BY MHSS PHYSICIAN


MHSS Physician consulted with employee’s attending physician and confirmed the employee’s illness Yes
No

MHSS Physician visited employee during illness: Yes No


Medical Certificate submitted to MIT Physician Yes No (Reason) ___________

RECOMEDATION:

Employee is physically fit to return to work assignment


Employee is still unfit to render service and advised to extend leave for additional ______days
Employee is still not fit to return to work assignment.

MHSS Physician/Date
TO BE FILLED BY DEPARTMENT/SECTION/OFFICE HEAD

Approved
Approved without pay
Disapproved

Ms. Venice Cristine C. Dangaran


Department Head / Date

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