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 aga
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

I. PERSONAL INFORMATION
2. SURNAME BARBA
NAME EXTENSION (JR., SR
FIRST NAME MAELA
MIDDLE NAME MAGNO
3. DATE OF BIRTH
(mm/dd/yyyy) FEB.08,1994 ✘ Filipino Dual Citizenship
by birth b
4. PLACE OF BIRTH MALATE,MANILA If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 019

Widowed Separated
House/Block/Lot No. S

Other/s:
SAPAN
Subdivision/Village Ba
7. HEIGHT (m) 160cm SAN ANDRES CATAN
City/Municipality Pr
8. WEIGHT (kg) 75kgs. ZIP CODE 4801

9. BLOOD TYPE O+
18. PERMANENT ADDRESS 019
House/Block/Lot No. S

10. GSIS ID NO. SAPAN

Subdivision/Village Ba

11. PAG-IBIG ID NO. 1211-4452-5567 SAN ANDRES CATAN

City/Municipality Pr

12. PHILHEALTH NO. 10-025143021-1 ZIP CODE 4801

13. SSS NO. 34-4480246-3 19. TELEPHONE NO. N/A

14. TIN NO. 429-960-733 20. MOBILE NO. 09059704518

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) N/A
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all)
NAME EXTENSION (JR., SR)
FIRST NAME N/A
MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A
TELEPHONE NO. N/A
24. FATHER'S SURNAME BARBA
NAME EXTENSION (JR., SR)
FIRST NAME ROMEO
MIDDLE NAME BRAGAIS
25. MOTHER'S MAIDEN NAME

SURNAME MAGNO
FIRST NAME MITZIE
MIDDLE NAME PANTI (Continue on separate sheet if necessary

III. EDUCATIONAL BACKGROUND

NAME OF SCHOOL HIGHEST LEVEL/
26. BASIC EDUCATION/DEGREE/COURSE PERIOD OF ATTENDANCE UNITS
LEVEL (Write in EARNED
(Write in full)
full) (if not graduated)
From To

ELEMENTARY SAN ANDRES CENTRAL ELEM.SCHOOL PRIMARY 2000 2006 N/A

SECONDARY SAN ANDRES VOCATIONAL SCHOOL SECONDARY 2006 2010 N/A

VOCATIONAL /

N/A N/A N/A N/A N/A

TRADE
COURSE
COLLEGE CATANDUANES STATE COLLEGES MIDWIFERY 2010 2012 N/A

BACHELOR OF SCIENCE IN
NAGA COLLEGE FOUNDATION 2015 2017 N/A
MIDWIFERY
BACHELOR OF SCIENCE IN
CATANDUANES COLLEGES 2018 2018 N/A
SECONDARY EDUCATION
GRADUATE STUDIES .
(Continue on separate sheet if necessary)
SIGNATURE DATE
CS FORM
L DATA SHEET
rience Sheet shall cause the filing of administrative/criminal case/s against the person

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization
Pls. indicate country:

Street
SAPANG PALAY
Barangay
CATANDUANES
Province
4801

Street
SAPANG PALAY
Barangay
CATANDUANES
Province

4801

N/A

09059704518

N/A

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

SCHOLARSHIP/
YEAR
ACADEMIC
GRADUATED
HONORS
RECEIVED

2006

2010 N/A
 N/A N/A

2012 N/A

2017 N/A

2017 N/A

parate sheet if necessary)

CS FORM 212 (Revised 2017), Page 1 of 4

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

BOARD OF MIDWIFERY 82.7% NOV.18-19,2012 LEGAZPI CITY

(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 SALARY/ JOB/
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY PAY GRADE (if
(mm/dd/yyyy) MONTHLY
(Write in full/Do not (Write in SALARY
applicable)& STEP
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To

01/03/2013 12/31/2013 RURAL HEALTH MIDWIFE DEPARTMENT OF HEALTH 6000

06/2014 12/2014 MIDWIFE ALABANG MEDICAL CLINIC 12000

RURAL HEALTH MIDWIFE ( RETURN
6/1/2017 Present DEPARTMENT OF HEALTH 20179
SERVICE)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 2
 LICENSE (if applicable)

NUMBER Date of
Validity

162809 FEB.8,2021

ue on separate sheet if necessary)

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

GOV'T SERVICE

STATUS OF
APPOINTMENT

(Y/ N)

CONTRACTUAL Y

CONTRACTUAL N

CONTRACTUAL Y
ue 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
INCLUSIVE DATES
29. NAME & ADDRESS OF ORGANIZATION
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION /
From To

(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/
NUMBER OF HOURS
(Write in full) Supervisory/
(mm/dd/yyyy)
Technical/etc)
From To

EXPANDED PROGRAM ON IMMUNIZATION 9/29/2015 9/29/2015 8 NAGA COLLE

8-DAYS BASIC EMERGENCY OBSTETRIC AND NEWBORN CARE (BEmONC) & ESSENTIAL
9/11/2015 11/16/2015 BICOL MEDIC
INTRAPARTUM AND NEWBORN CARE COURSE FOR MIDWIVES
NAGA COLLE
FAMILY PLANNING COMPETENCY FPCBT LEVEL 1 7/12/2015 11/12/2015
LYING IN CLIN
NAGA COLLE
FAMILY PLANNING COMPETENCY FPCBT LEVEL 2 12/12/2015 12/16/2015
LYING IN CLIN
NAGA COLLE
"USAPAN'' FACILITATORS TRAINING (CONVERSATION SERIES) 7/1/2016 11/1/2016
LYING IN CLIN

45 HOURS BASIC CALL CENTER TRAINING COURSE (BPO) 2/5/2016 5/17/2016 NAGA COLLE

TRAININGS OF TRAINERS (TOT) ON EINC 1/6/2016 3/6/2016 NAGA COLLE

NAGA COLLE
20 HOURS LACTATION MANAGEMENT TRAINING 06/29/2016 1/7/2016
LYING IN CLIN
SKILLS MANAGEMENT TRAINING ON ACCESSING GRANTS ON FOREIGN GOVERNMENT
1/3/2017 3/3/2017 NAGA COLLE
FOR LOCAL DEVELOPMENT PROJECTS

30 HOURS BASIC JAPANESE LANGUAGE COURSE 1 4/3/2017 03/18/2017 NAGA COLLE

NAGA COLLE
EMEGENCY FIRST AID AND BLS/CPR FOR LAY RESCUE 03/23/2017 03/24/2017
CALABANGG

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

MEMBERS
NON-ACADEMIC DISTINCTIONS / RECOGNITION
31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full)
 (Continue on separate sheet if necessary)

SIGNATURE DATE
/ PEOPLE / VOLUNTARY ORGANIZATION/S

POSITION / NATURE OF WORK

eparate sheet if necessary)

ROGRAMS ATTENDED
five (5) years for Division Chief/Executive/Managerial positions)

CONDUCTED/ SPONSORED BY
(Write in full)

NAGA COLLEGE FOUNDATION

BICOL MEDICAL CENTER

NAGA COLLEGE FOUNDATION/BICOL ISAROG

LYING IN CLINIC
NAGA COLLEGE FOUNDATION/BICOL ISAROG
LYING IN CLINIC
NAGA COLLEGE FOUNDATION/BICOL ISAROG
LYING IN CLINIC

NAGA COLLEGE FOUNDATION

NAGA COLLEGE FOUNDATION

NAGA COLLEGE FOUNDATION/BICOL ISAROG

LYING IN CLINIC

NAGA COLLEGE FOUNDATION

NAGA COLLEGE FOUNDATION

NAGA COLLEGE FOUNDATION/RED CROSS

CALABANGGA CHAPTER

eparate sheet if necessary)

MEMBERSHIP IN ASSOCIATION/ORGANIZATION
(Write
in full)
eparate sheet if necessary)

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? YES ✘

b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘

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 regulation
YES ✘ NO
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 phased If YES, give details:
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 YES ✘ NO
Barangay election)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last YES ✘ NO
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 items:
a. 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
3.5 cm. X 4.5 cm
(passport size)

With full and handwritten

name tag and signature over
printed name

Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and or photocopied picture
is not acceptable
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 PROFESSIONAL
Government Issued ID: REGULATORYCOMMISSION
IDENTIFICATION
ID/License/Passport No.: 162809 Signature (Sign inside the box)

Date/Place of Issuance: NOVEMBER 24,2012 LEGAZPI CITY

Date Accomplished Right Thumbmark
If YES, give details (country):