IV.

CIVIL SERVICE ELIGIBILITY

27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicab
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

N/A

(Continue on separate sheet if necessary)

V. WORK EXPERIENCE
(Include private employment. Start from your recent work) Description of duties should be indicated in the attached Work Experience sheet.
28. INCLUSIVE DATES
(mm/dd/yyyy) SALARY/ JOB/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
MONTHLY STATUS OF
(Write in full/Do SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
not abbreviate) (Write in full/Do not abbreviate) INCREMENT
From To

6/1/2019 12/31/2019 CERTIFIED NURSING ASSISTANT SURIGAO MEDICAL CENTER 12,000.00 JOB ORDER

CONTRACT OF
1/10/2018 12/31/2018 PUBLIC HEALTH ASSOCIATE(PHADP) DEPARTMENT OF HEALTH (DOH) 22,149.00 GRADE 11
SERVICE

CONTRACT OF
2/6/2017 12/31/2017 PUBLIC HEALTH ASSOCIATE(PHADP) DEPARTMENT OF HEALTH (DOH) 19,940.00
SERVICE

CONTRACT OF
1/27/2016 12/31/2016 PUBLIC HEALTH ASSOCIATE(PHADP) DEPARTMENT OF HEALTH (DOH) 19,940.00
SERVICE

CONTRACT OF
10/5/2015 12/31/2015 PUBLIC HEALTH ASSOCIATE(PHADP) DEPARTMENT OF HEALTH (DOH) 14, 931.00
SERVICE

4/2/2014 10/2/2015 NURSING AIDE CITY HEALTH OFFICE 4000.00 JOB ORDER

2/1/2008 6/30/2010 NURSING AIDE CITY HEALTH OFFICE 4000.00 JOB ORDER
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Pa
 LICENSE (if applicable)

Date of
Validity

on separate sheet if necessary)

ion of duties should be indicated in the attached Work Experience sheet.

GOV'T
SERVICE

(Y/
N)

Y
on separate sheet if necessary)

CS FORM 212 (Revised 2017), Page 2 of 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29. (Write in
full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

N/A

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
(Start from the most recent L&D/training program and include only the relevant L&D/training taken for the last five (5) years for Division Chief/Executive/Managerial positions)
INCLUSIVE DATES OF
TITLE OF LEARNING AND DEVELOPMENT ATTENDANCE Type of LD
30. ( Managerial/ CONDUCTED/ SPONSORED BY
INTERVENTIONS/TRAINING PROGRAMS NUMBER OF HOURS
Supervisory/
(mm/dd/yyyy) (Write in full)
(Write in full) From To Technical/etc)

SEMINAR ON RATIONAL BLOOD USE 10/25/2019 10/25/2019 8.0 SURIGAO MEDICAL CENTER

NEGLECTED TROPICAL DISEASES

MANAGEMENT INFORMATION SYSTEM 11/12/2018 11/13/2018 16.0 DEPARTMENT OF HEALTH RO-XIII
TRAINING

DATA QUALITY CHECK TRAINING ON HEALTH

SECTOR PERFORMANCE MONITORING AND 11/7/2018 11/9/2018 24.0 DEPARTMENT OF HEALTH RO-XIII
EVALUATION

USER'S ORIENTATION ON MOBILE

APPLICATION OF HEALTH FACILITY PROFILE 9/19/2018 9/20/2018 16.0 DEPARTMENT OF HEALTH RO-XIII
AND NATIONAL HEALTH FACILITY REGISTRY

DATA ANALYSIS AND RESEARCH TRAINING-

8/15/2018 8/17/2018 24.0 DEPARTMENT OF HEALTH RO-XIII
WORKSHOP

Integrated Clinic Information System

(Iclinicsys)Regional Training of Trainers (TOT) for 6/5/2018 6/6/2018 16.0 DEPARTMENT OF HEALTH RO-XIII
Human Resource for Health.

ORIENTATION ON HEALTH SECTOR

8/16/2017 8/17/2017 16.0 DEPARTMENT OF HEALTH RO-XIII
PERFORMANCE MONITORING

ORIENTATION ON THE COLLECTION OF THE

2017 HEALTH FACILITY PROFILE FOR REGION 11/23/2017 11/24/2017 16.0 DEPARTMENT OF HEALTH RO-XIII
XIII-CARAGA

HRH ORIENTATION ON GLOBAL POSITIONING

SYSTEM AND GEOGRAPHIC INFORMATION 12/28/2016 12/29/2016 16.0 DEPARTMENT OF HEALTH RO-XIII
SYSTEM

COMPUTER ENHANCEMENT TRAINING (BASIC

9/29/2016 9/30/2016 16.0 DEPARTMENT OF HEALTH RO-XIII
COMPUTER TROUBLESHOOTING)

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION
MEMBERSHIP IN
NON-ACADEMIC DISTINCTIONS / RECOGNITION ASSOCIATION/ORGANIZATION
31. SPECIAL SKILLS and HOBBIES 33.
(Write in full) (Write
in full)

COMPUTER LITERATE N/A

KNOWLEGEBLE ON DOCUMENTARY WORKS

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 3 of 4
 34. Are you related by consanguinity or affinity to the appointing or recommending authority, or
to theof bureau or office or to the person who has immediate supervision over you in the
chief
Office,
Bureau or Department where you will be apppointed,
a. within the third degree? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
If YES, give details:
________________________________

35. a. Have you ever been found guilty of any administrative offense? YES ✘ NO
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court? YES ✘ NO
If YES, give details:
________________________________
Date Filed:
________________________________
Status of Case/s:

36. Have you ever been convicted of any crime or violation of any law, decree, ordinance or
YES ✘ NO
regulation by any court or tribunal?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation, YES ✘ NO
retirement, dropped from the rolls, dismissal, termination, end of term, finished contract or If YES, give details:
phased out (abolition) in the public or private sector? ________________________________
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year
YES ✘ NO
(except Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before YES ✘ NO
the last election to promote/actively campaign for a national or local candidate? If YES, give details:
39. Have you acquired the status of an immigrant or permanent resident of another country?
YES ✘ NO
If YES, give details (country):

40. Pursuant to: (a) Indigenous People's Act (RA 8371); (b) Magna Carta for Disabled Persons
(RA 7277); and (c) Solo Parents Welfare Act of 2000 (RA 8972), please answer the following
a.
items:
Are you a member of any indigenous group?
YES ✘ NO
If YES, please specify:
b. Are you a person with disability? YES ✘ NO
If YES, please specify ID No:
c. Are you a solo parent? YES ✘ NO
If YES, please specify ID No:

41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within
the last 6 months
ERWIN G. PINGAL, RMT, MPM SURIGAO CITY 09479877392 3.5 cm. X 4.5 cm
(passport size)

LUCITA O. TAGUDIN, RN, MCH SURIGAO CITY 09985682309 With full and handwritten
name tag and signature over
printed name
CATHERINE B. OLVIS,RN SURIGAO CITY 09127017546
Computer generated
or photocopied picture
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct is not acceptable
and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of
the Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated
herein. I agree that any misrepresentation made in this document and its attachments shall cause the PHOTO
filing of administrative/criminal case/s against me.

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance
Government Issued ID: UMID

ID/License/Passport No.: 0111-8390438-1

Signature (Sign inside the box)

Date/Place of Issuance: SURIGAO CITY

Date Accomplished Right Thumbmark

SUBSCRIBED AND SWORN to before me this , affiant exhibiting his/her validly issued government ID as indicated above.

Person Administering Oath

CS FORM 212 (Revised 2017), Page 4 of 4