Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

Ref. Reference
Key Activities Responsibilities
No. Document / Record
1 ▪ DOH announces ▪ DOH-HHRDB ▪ Department
the availability of ▪ DOH-ROs Memorandum
Announcement the scholarship
grant through the
of Scholarship
Regional Offices
Grant offered

2 ▪ Students shall ▪ Partner schools ▪ List of potential

apply directly to the scholars
school and should
Application and meet the minimum
Screening requirements set by
the partner
institution

Only those who

have been admitted
to the partner
schools are eligible
to apply for the
DOH scholarship

3 ▪ Partner school shall ▪ DOH ▪ Department

Evaluation and submit the list of Scholarship Personnel Order
approval of potential scholar to committee
DOH for evaluation
successful
and approval of the
scholars DOH Scholarship
Committee

Successful scholars
shall be notified
through the
Scholarships
Department of the
schools

▪ Department ▪ DOH-HHRDB
Personnel Order
shall be prepared
for the Scholars

jbp/cdmd/hhrdb/16-20

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Trunk Line 651-7800 local 1113, 1108, 1135
Direct Line: 711-9502; 711-9503Fax: 743-1829 ● URL: http://www.doh.gov.ph; e-mail: officeofsoh@doh.gov.ph
1 of 3
Ref. Reference
Key Activities Responsibilities
No. Document / Record
4 ▪ Students shall be ▪ DOH-HHRDB ▪ Scholarship
provided with the and ROs contract for
Signing of Scholarship students
Contracts and Contract through ▪ Memorandum of
MOA the Regional Agreement with
Offices partner schools
▪ Partner schools
shall sign a MOA
with the DOH for
the implementation
of the grant
5 ▪ Partner schools ▪ Partner school ▪ Performance
shall submit reports and
Monitoring of performance recommended
Academic reports to the actions
Regional Offices at
Performance
the end of every
school year
semester with
appropriate
recommendations
on the scholarship
of the students
▪ Regional Offices ▪ DOH-RO
shall provide
updates to HHRDB
on the status of the
scholarships grant
at the end of every
school year
semester with
appropriate
recommendations
on the scholarship
of the students and
the performance of
the partner schools

6 ▪ Schools shall ▪ Partner school ▪ List of students that

provide DOH the graduated
Rendering of list of successful ▪ List of board takers
graduates and ▪ List of board
return service those who have passers
obligations failed to finish the
course with
complete contact
details of the
students
▪ Schools shall also
provide DOH the
list of student who
opted to take the
board exam and
those who did not

2 of 3
Ref. Reference
Key Activities Responsibilities
No. Document / Record
▪ Schools shall also
provide the list of
passers and those
who have failed the
exams
▪ Schools shall
coordinate with the
scholars to report
to the respective
Regional Office
upon passing the
board examination
▪ Students shall ▪ DOH-ROs
render (two) 2
years of service for
every one (1) year
of scholarship grant

3 of 3
 List of partner schools from Region I and II for
the DOH Pre Service Scholarship Program

Medical Scholarship
REGION I University of Northern Philippines
REGION II Cagayan State University

Midwifery Scholarship
REGION I Union Christian College
REGION I Urdaneta City University
REGION I Eastern Pangasinan University
Don Mariano Marcos Memorial State
REGION I
University
REGION I North Luzon Philippines State College
REGION II Isabela State University
REGION II Quirino State University
 SELECTION CRITERIA FOR SCHOLARS

Name of Applicant: ___________________________________________ Date Evaluated: __________

Address: ____________________________________________________

SUMMARY

Category Weight Score

Category 1: Citizenship 5 SCORING:
Category 2: Health Condition 5 1st Priority: more than 36
Category 3: School Admission 5 2ndPriority: 25– 35
Category 4: Residence Not a Priority: less than 25
4a: GIDA 10
4b: CADT Area/Indigenous Community 10
4c: Municipality Class/ City 5
4d: 20 Poorest Province 5
Category 5: Income (Monthly Gross) 10
Category 6: Affiliation 5
Total 60

CATEGORY 1: CITIZENSHIP
Criteria Weight Score
Filipino 5
Non- Filipino 0
Total

CATEGORY 2: HEALTH CONDITION

Criteria Weight Score
Physically and mentally fit 5
With illness 0
Total

CATEGORY 3: SCHOOL ADMISSION

Criteria Weight Score
Passed 5
Declined 0
Total

CATEGORY 4: RESIDENCE
Category 4a: Geographically Isolated and Disadvantaged Areas (GIDA)
Criteria Weight Score
GIDA 10
Non- GIDA 0
Total

Category 4b: Certificate of Ancestral Domain Title (CADT) Area/Indigenous Community

Criteria Weight Score
CADT Area/Indigenous Community 10
Non- CADT Area/ Non- Indigenous Area 0
Total

Category 4c: Municipality Class/ City

Criteria Weight Score
Sixth Class 5
1 of 2
cev/cdmd/hhrdb/17-9
 Criteria Weight Score
Fifth Class 4
Fourth Class 3
Third Class 2
Second Class 1
First Class 0
City 0
Total

Category 4d: 20 Poorest Province

Criteria Weight Score
Lanao del Sur (ARMM) 5
Maguindanao (ARMM) 5
Sulu (ARMM) 5
Mt. Province (CAR) 5
Agusan del Sur (Caraga) 5
Catanduanes (Region 5) 5
Sorsogon (Region 5) 5
Negros Oriental (Region 7) 5
Siquijor (Region 7) 5
Eastern Samar (Region 8) 5
Leyte (Region 8) 5
Northern Samar (Region 8) 5
Western Samar (Region 8) 5
Zamboanga del Norte (Region 9) 5
Zamboanga Sibugay (Region 9) 5
Bukidnon (Region 10) 5
Lanao del Norte (Region 10) 5
North Cotabato (Region 12) 5
Sarangani (Region 12) 5
Sultan Kudarat (Region 12) 5
Total

CATEGORY 5: INCOME (COMBINED MONTHLY GROSS FAMILY)

Criteria Weight Score
Php 30,000.00 per family member 0
Php 20,000.00 – 29,999.00 per family member 5
<Php19,999.00 per family member 10
Total

CATEGORY 6: AFFILIATION
Criteria Weight Score
Member of Minority Sector (e.g.Manobo, Aeta, Mangyan, Tausug, Maranao, Badjao, etc) 5
Dependent of Government Employee 5
Dependent of Barangay Health Worker 5
Dependent of Traditional Birth Attendant 5
Dependent of Police/ Soldier Fatally Wounded/ Killed on Duty 5
Victim of Calamities/ insurgencies 5
Total

Evaluated by: Noted by:

__________________________ ___________________________________
<NAME> <NAME>
Position/Designation Regional Director

2 of 2
cev/cdmd/hhrdb/17-9
 Republic of the Philippines
Department of Health
Paste a recent 1” x 1”
DOH SCHOLARSHIP PROGRAM photograph (taken
APPLICATION FORM within the last 6 months)
in this box.
Print legibly and use separate sheet if necessary. Place marks in appropriate boxes. Only accomplished application forms will be processed.
SCHOLARSHIP APPLIED FOR:
 Medical Scholarship Program
 Midwifery Scholarship Program

PERSONAL BACKGROUND
[ ] Member of Ethnic Minority or [ ] Barangay Health Worker – Child [ ] Government Staff – Child
Indigenous People
Specify:_____________________ [ ] Traditional Birth Attendant - Child [ ] Victim of Calamity/ Insurgency
NAME:
(Surname) (First Name) (Middle Name)
DATE OF BIRTH: PLACE OF BIRTH:

AGE: GENDER: CIVIL STATUS: NATIONALITY: Religious Affinity:

[ ]Female [ ] Singe [ ] Widowed
[ ]Male [ ] Married [ ] Separated
PERMANENT ADDRESS: Tel #:

MAILING ADDRESS: Tel #:

CELLPHONE # (if any) E-MAIL ADDRESS: (if any)

TIN #: Philhealth # (if any)

LBP Account: (if any) LBP Branch:

FAMILY BACKGROUND
Father’s Name: Age: Occupation: Salary:

Mother’s Name: Age: Occupation: Salary:

Spouse’s Name: Age: Occupation: Salary:

Gross Monthly Family Names of Children: Age(s)

Number of siblings ______ Income: __________________________ __________
__________________________ __________
Sibling Rank ______ __________________________ __________
______

EDUCATIONAL BACKGROUND
INCLUSIVE SCHOLARSHIP/
HIGHEST GRADE
DATES OF HONOR(S) /
LEVEL NAME OF SCHOOL FINISHED OR
ATTENDANCE DISTINCTION
DEGREE EARNED
From To RECEIVED

ELEMENTARY

SECONDARY

VOCATIONAL /
TRADE COURSE

COLLEGE

GRADUATE
STUDIES

Page 1 of 2
EMPLOYMENT / SERVICE RECORD (Start from current work)
INCLUSIVE STATUS OF MONTHLY
POSITION TITLE OFFICE/COMPANY
DATES EMPLOYMENT SALARY

REFERENCES
Please provide at least two (2) character references you are not related to.

NAME POSITION & ADDRESS CONTACT NO.

I declare that all information and documents submitted with this application form are true and correct 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 trust that this
information shall remain confidential.

_____________________________
Applicant’s Signature over
Printed Name

__________________________
Date

Attachments:

1. Copy of Barangay Certification/ Certification of a Bona Fide Resident of the Community

2. Copy of Combined Family Income Tax Return (ITR)
3. Certificate of Indigency (if applicable)
4. Certification from National Commission on Indigenous Peoples (NCIP) (if applicable)

Page 2 of 2