CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misinterpretation made in the Personal Data Sheet and the Work Experience Sheet shall cause the filing of administrative/criminal case/s against the person
concerned.
READ THE ATTACHED GUIDE TO FILLING OUT THE PERSONAL DATA SHEET (PDS) BEFORE ACCOMPLISHING THE PDS FORM.
Print legibly. Tick appropriate boxes ( ) and use separate sheet if necessary. Indicate N/A if not applicable. DO NOT ABBREVIATE. 1. CS ID No. (Do not fill up. For CSC use only)

I. PERSONAL INFORMATION
2. SURNAME

FIRST NAME NAME EXTENSION (JR., SR) N/A

MIDDLE NAME

3. DATE OF BIRTH
16. CITIZENSHIP
(mm/dd/yyyy)

4. PLACE OF BIRTH If holder of dual citizenship, Pls. indicate country:

please indicate the details.
5. SEX

17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
House/Block/Lot No. Street

Subdivision/Village Barangay

7. HEIGHT (m)
City/Municipality Province
8. WEIGHT (kg) ZIP CODE

18. PERMANENT ADDRESS

9. BLOOD TYPE
House/Block/Lot No. Street

10. GSIS ID NO. N/A

Subdivision/Village Barangay

11. PAG-IBIG ID NO. N/A

City/Municipality Province

12. PHILHEALTH NO. ZIP CODE

13. SSS NO. 19. TELEPHONE NO. NONE

14. TIN NO. 20. MOBILE NO.

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any)

II. FAMILY BACKGROUND

DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
(mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME
NAME EXTENSION (JR., SR) N/A
FIRST NAME

MIDDLE NAME

25. MOTHER'S MAIDEN NAME

SURNAME

FIRST NAME

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

HIGHEST LEVEL/ SCHOLAR
26. NAME OF SCHOOL BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE SHIP/
UNITS YEAR
LEVEL (Write in (Write in full) EARNED GRADUATED
ACADEMIC
HONORS
full) (if not graduated) RECEIVED
From To

ELEMENTARY N/A

SECONDARY /
VOCATIONAL N/A

N/A
TRADE
COURSE
COLLEGE N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER DATE OF LICENSE (if applicable)
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity

MIDWIFERY LICENSURE EXAMINATION 78.35 NOV. 12-13, 2011 MLQU MANILA 0158466 12/23/2020

(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.
GOV'T
SALARY/ JOB/ SERVICE
28. INCLUSIVE DATES PAY GRADE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY
(mm/dd/yyyy) (if applicable)&
(Write in full/Do not MONTHLY SALARY STEP (Format STATUS OF APPOINTMENT
(Write in full/Do not abbreviate) abbreviate) "00-0")/
From To INCREMENT
(Y/ N)
DEPARTMENT OF HEALTH / CENTER FOR
6/3/2019 PRESENT MIDWIFE II HEALTH DEVELOPMENT CALABARZON R 20,754.00 ''11-1'' CONTRACTUAL Y
MIDWIFE I (RURAL HEALTH MIDWIFE DEPARTMENT OF HEALTH / CENTER FOR
10/1/2018 12/31/2018 PLACEMENT PROGRAM) HEALTH DEVELOPMENT CALABARZON R 20,179.00 ''11-1'' JOB ORDER N
MIDWIFE I (RURAL HEALTH MIDWIFE DEPARTMENT OF HEALTH / CENTER FOR
7/9/2018 9/30/2018 PLACEMENT PROGRAM) HEALTH DEVELOPMENT CALABARZON R 20,179.00 ''11-1'' JOB ORDER N
MIDWIFE I (RURAL HEALTH MIDWIFE DEPARTMENT OF HEALTH / CENTER FOR
2/5/2018 6/30/2018 PLACEMENT PROGRAM) HEALTH DEVELOPMENT CALABARZON R 20,179.00 ''11-1'' JOB ORDER N
MIDWIFE I (RURAL HEALTH MIDWIFE REGIONAL OFFICE 4A CALABARZON /
7/10/2017 12/31/2017 PLACEMENT PROGRAM) DEPARTMENT OF HEALTH R 14,931.00 ''8-1'' JOB ORDER N
MIDWIFE I (RURAL HEALTH MIDWIFE REGIONAL OFFICE 4A CALABARZON /
1/23/2017 6/30/2017 PLACEMENT PROGRAM) DEPARTMENT OF HEALTH R 14,931.00 ''8-1'' JOB ORDER N
MIDWIFE I (RURAL HEALTH MIDWIFE REGIONAL OFFICE 4A CALABARZON /
1/ /2016 12/31/2016 PLACEMENT PROGRAM) DEPARTMENT OF HEALTH R 14,931.00 ''8-1'' JOB ORDER N
MIDWIFE I (RURAL HEALTH MIDWIFE REGIONAL OFFICE 4A CALABARZON /
1/ /2015 12/31/2015 PLACEMENT PROGRAM) DEPARTMENT OF HEALTH R 14,931.00 ''8-1'' JOB ORDER N
RHMPP TRAINING CUM REGIONAL OFFICE 4A CALABARZON /
1/8/2014 12/31/2014 R 6,000.00 N/A JOB ORDER N
DEPLOYMENT DEPARTMENT OF HEALTH
RURAL HEALTH MIDWIFE
REGIONAL OFFICE 4A CALABARZON /
8/13/2013 12/31/2013 PLACEMENT PROGRAM (RHMPP) DEPARTMENT OF HEALTH R 6,000.00 N/A JOB ORDER N
BATCH 4-A
RURAL HEALTH MIDWIFE
REGIONAL OFFICE 4A CALABARZON /
3/1/2012 3/31/2013 PLACEMENT PROGRAM (RHMPP) DEPARTMENT OF HEALTH R 6,000.00 N/A JOB ORDER N
BATCH 3

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 1, 2020
CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

BARANGAY HEALTH WORKER (BHW)

KALAYAAN, LAGUNA 1/10/2007 6/30/2019 1800 HOURS MEMBER /VOLUNTEER

PHILIPPINE RED CROSS LAGUNA CHAPTER

1/1/2010 PRESENT 1440 HOURS VOLUNTEER INSTRUCTOR
STA CRUZ, LAGUNA

(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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
ADVOCACY & AWARENESS SEMINAR ON PNEUMOCOCCAL CONJUGATE DEPARTMENT OF HEALTH/ CENTER FOR
11/18/2019 11918/2015 8 HOURS TECHNICAL
VACCINE (PCV13) HEALTH DEVELOPMENT CALABARZON
REVISED FAMILY PLANNING COMPETENCY BASED TRAINING (FPCBT) LEVEL 1 DEPARTMENT OF HEALTH/ CENTER FOR
10/7/2019 10/11/2019 40 HOURS TECHNICAL
HEALTH DEVELOPMENT CALABARZON
ORIENTATION OF NEWLY HIRED HUMAN RESOURCE FOR HEALTH (HRH) OF DEPARTMENT OF HEALTH/ CENTER FOR
7/8/2019 7/10/2019 16 HOURS TECHNICAL
LAGUNA HEALTH DEVELOPMENT CALABARZON
STANDARD FIRST AID & CPR/AED 6/26/2018 6/29/2018 32 HOURS TECHNICAL RURAL HEALTH UNIT KALAYAAN
WATER SAFETY AND RESCUE OPERATIONS TRAINING MUNICIPAL DISASTER RISK REDUCTION
5/17/2017 5/19/2017 24 HOURS TECHNICAL
MANAGEMENT-KALAYAAN LAGUNA
CEBU CITY CONDUCTED BY PHILIPPINE
18 NATIONAL GENERAL ASSEMBLY OF MIDWIFES
4/18/2017 4/21/2017 32 HOURS TECHNICAL LEAGUE OF GOVERNMENT AND PRIVATE
MIDWIVES SUPPORT THE CHANGE:CHALLENGE ACCEPTED ACHIEVE!
MIDWIVES, INC
RAPID DAMAGE ASSESSMENT AND NEEDS ANALYSIS (RDANA) TRAINING MUNICIPAL DISASTER RISK REDUCTION
3/27/2018 3/29/2018 24 HOURS TECHNICAL
COURSE MANAGEMENT-KALAYAAN LAGUNA
TRAINING ON THE REVISED NATIONAL TB CONTROL PROGRAM-MANUAL DEPARTMENT OF HEALTH/ CENTER FOR
9/26/2017 9/28/2017 24 HOURS TECHNICAL
PROCEDURE 5TH EDITION HEALTH DEVELOPMENT CALABARZON

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33. (Write in
(Write in full)
full)
TEACHING/INSTRUCTOR MOST COURTEOUS GRADE 6 BARANGAY HEALTH WORKER
COOKING MOST DEPENDABLE 2ND YR HIGH SCHOOL RED CROSS VOLUNTEER
TYPING MOST BEHAVE 3RD YEARD HIGH SCHOOL

MOST BEHAVE 4TH YEAR HIGH SCHOOL

BLOOD GALLONERS AWARD

BRONZE BLOOD GALLONERS AWARD

DIPLOMA MERIT MEDAL BRONZE (RED CROSS LAGUNA CHAPTER)

(Continue on separate sheet if necessary)

SIGNATURE DATE JANUARY 1, 2020

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 the
chief of bureau or office or to the person who has immediate supervision over you in the Office,
Bureau or Department where you will be apppointed,
a. within the third degree?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details: ________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details: ________________________________
________________________________

b. Have you been criminally charged before any court?

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
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,
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 (except
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before 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?
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 items:
a. Are you a member of any indigenous group?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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
3.5 cm. X 4.5 cm
EDELANE R. ACUEZA, RN RHU KALAYAAN 09275011041 (passport size)

With full and handwritten

NECITAS H. BAYAWA,RN,MAN CHO CALAMBA 09178175229 name tag and signature over
printed name

JOSE D. MANGUNAY JR,RN PHTO LAGUNA 09993738257 Computer generated

or photocopied picture
is not acceptable
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct 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 filing of PHOTO
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: PRC ID
ID/License/Passport No.: 0158466 Signature (Sign inside the box)
JANUARY 1, 2020
Date/Place of Issuance: 2-22-2017 PRC LUCENA
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