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Leave Form

The Leave Application Form is designed for employees to request various types of leave, including medical, bereavement, maternity, paternity, solo-parent, major illness, and special leave for women. Employees must complete the form with required supporting documents and obtain signatures from both themselves and their supervisor before submission to HR for approval. Important reminders emphasize that submission does not excuse employees from call-in procedures and that HR has the final authority on leave approvals based on company guidelines.

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bernardo.s.carrascal
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56 views2 pages

Leave Form

The Leave Application Form is designed for employees to request various types of leave, including medical, bereavement, maternity, paternity, solo-parent, major illness, and special leave for women. Employees must complete the form with required supporting documents and obtain signatures from both themselves and their supervisor before submission to HR for approval. Important reminders emphasize that submission does not excuse employees from call-in procedures and that HR has the final authority on leave approvals based on company guidelines.

Uploaded by

bernardo.s.carrascal
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

Employee Name Employee Number

Account/Department Date filed


Number of Leave Credits
Contact Number Remaining

Inclusive Dates of Leave Application Date of Crediting


Original Schedule
(For HR USE Only)
Day Time Rest Day Start Date End Date Maternity MIB

Please provide checkmark on the appropriate option


No. of Days Leave
Type of Leave Documents Attached
Provided Category
Medical-related as approved PTO Medical certificate related to hospitalization
Bereavement 7 max PTO Death certificate of deceased family member (indicate relationship)
Original Ultrasound Film
Original Ultrasound Report
Photocopy of 2 valid IDs (affix 3 signatures)
OB History form to be filled out by OB Gyne
Maternity 60/98/105/120 SSS Employee Maternity Benefit Acknowledgement Form
SSS MAT1 (Accomplished in BLACK INK)
Print-out of Contributions from SSS website
Valid Solo Parent ID (120 days)
SSS Allocation and Intent Letter (98 days)

7 annually Birth certificate of new born child and Marriage Certificate (2 sets)
Paternity additional
7 (Allocation) Certificate of Acceptance (Allocation)

Solo-Parent 7 annually additional Photocopy of Valid Solo-parent ID card or certificate(2 sets)


Major Illness
6 to 10 additional Medical certificate related to the illness
Benefit
Special Leave for 60 calendar Operating Room Record, Discharge Summary, Medical Certificate as validated by
Women days the Company Physician
additional

Reason for Leave:


Important Reminders:

• The submission of the leave application form is primarily for the purpose of the benefit approval & implementation
and does not excuse an employee from the call-in procedure.
• This FORM must be fully accomplished, signed by both employee and supervisor, and submitted to Site HR with
complete supporting documents, and officially signed by authorized personnel. Approval of inclusive dates shall be
dependent on the issuance date and the number of days specified in the medical certificate.
• For medical-related leaves:
o HR has the final authority to approve/disapprove leave applications based on company medical guidelines.
o In the absence of PTO credits, the employee may file for SSS Sickness Benefit if the absence is at least for 4
consecutive calendar days. The employee should immediately notify Site HR within 5 calendar days from the start
of the illness by submitting the Sickness Notification Form.

(Print name & Signature)

__________________________ __________________________
Employee Supervisor

For HR use only:

HR Approval / Encoding

(Name & Date)

DATA CLASS 3 – HIGHLY CONFIDENTIAL

This document is owned by Teleperformance. This document is for authorized personnel only. Distribution to external parties without
management approval and duly signed confidentiality agreements is prohibited.

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