EDR 9
MINISTRY OF EDUCATION
APPLICATION FOR SICK LEAVE AND EXTENDED SICK LEAVE
ED. RULES 78 (12), S.I. 87 of 2012
A. Short Term Sick Leave of less than 10 days: Application form must be completed in DUPLICATE and
submitted to the Managing Authority, through the Principal, as soon as possible but no later than the
third day of such illness.
B. Extended Sick Leave in excess of 10 days and up to 180 days: Application form must be completed
in TRIPLICATE and submitted to the Managing Authority, through the Principal, as soon as possible.
Managing Authority must submit application with documentation and recommendation to Commission
for approval.
Procedures:
1. Submission of A. APPLICANT’S BIOGRAPHICAL DATA
completed form to 1. LICENCE NO.
Principal.
2. Principal verifies 2. NAME
particulars as
required. Last Name First Name Middle Name
3. Copy of form 3. PRESENT
forwarded to POST
Managing Authority. 4. SCHOOL
4. Managing Authority
approves sick leave 5. DISTRICT
of less than 10 days
and copy sent to 6. MANAGING
TSC Secretariat. AUTHORITY
5. Managing Authority 7. Number of day(s) applied for:
informs Principal and
Teacher as in 4. FROM TO
Above.
6. For extended sick
leave, Managing
Authority submits
D M Y D M Y
application to
Commission with
documentation, for
approval.
8. Nature of Illness:
B. CERTIFICATION
9. (a) Certification for Sick Leave of 1 –2 days:
Verification of Details I hereby certify that the above information is true and accurate.
Teacher was absent on
day(s) stated:
Yes No
Signature of Applicant D M Y
Medical / Health Practitioner 9. (b) Certification for Sick Leave of 3 or more days or for any period
works in this region:
exceeding six uncertified days sick leave: To be completed by a
Medical Practitioner or where such services are not obtainable
Yes No within the time specified, signed by a Health Practitioner or
Pharmacist in the region.
I hereby certify that
PLACE STAMP HERE
________________________________________
has been examined by me and I find him/her to be unfit for the
execution of duties due to ___________________________________
and has, therefore been placed on __________ days sick leave from
____________________to ______________________ (inclusive).
(D/M/Y) (D/M/Y)
Name of medical
practitioner (print)
District
Signature of Medical Practitioner D M Y
FOR OFFICE USE
Application Received: By:
PRINCIPAL
D M Y Signature
Verification of Details Completed By:
D M Y Signature
MANAGING AUTHORITY
Application Received: By:
D M Y Signature
Leave Granted:
days Certified by Teacher
days Certified by Medical / Health Practitioner
Copy of application form returned to Principal
Signature D M Y
FOR OFFICE USE: EXTENDED SICK LEAVE
Application Received: By:
MANAGING
AUTHORITY
D M Y Signature
Verification of Details Completed By:
D M Y Signature
TEACHING SERVICE Application Received: By:
COMMISSION
D M Y Signature
Leave Approved:
days Certified by Teacher
days Certified by Medical / Health Practitioner
Copy of application form returned to Managing Authority
Sick Leave up to 180 days approved with full pay
Replacement Teacher Approved
Signature D M Y
FOR OFFICE USE: EXTENDED SICK LEAVE BEYOND 180 DAYS
Application Received: By:
MANAGING AUTHORITY
D M Y Signature
Verification of Details Completed By:
D M Y Signature
TEACHING SERVICE Application Received: By:
COMMISSION
D M Y Signature
Commission requests Medical Board report
Medical Board report submitted indicating need for further leave:
Full Recovery Probable.
D M Y
Leave Approved:
days Certified by Teacher
days Certified by Medical Board
Copy of application form returned to Managing
TEACHING SERVICE Authority
COMMISSION
Further Sick Leave up to 180 days approved with
half pay
Replacement Teacher Approved
Signature D M Y
FOR OFFICE USE: EXTENDED SICK LEAVE BEYOND 180 DAYS
Application Received: By:
MANAGING
AUTHORITY
D M Y Signature
Verification of Details Completed By:
D M Y Signature
TEACHING SERVICE Application Received: By:
COMMISSION
D M Y Signature
Commission requests Medical Board report
D M Y
Medical Board report submitted indicating need for further leave:
Full Recovery not Probable.
D M Y
Commission requests Director of Medical Services Medical Board
To determine fitness to continue in the teaching service.
Teacher medically unfit to continue in the teaching
service.
Commission recommends retirement on Medical
grounds.
Copy of application form returned to Managing
TEACHING SERVICE Authority.
COMMISSION
Further Sick Leave up to 180 days denied.
Replacement Teacher Approved.
Signature D M Y
