CS Form No.

212
Revised 2017

PERSONAL DATA SHEET

WARNING: Any misrepresentation 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 LEAL
NAME EXTENSION (JR., SR)
FIRST NAME KATHLEEN ANNE

MIDDLE NAME LEGASPI

3. DATE OF BIRTH
(mm/dd/yyyy) 5/8/1998 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by birth by naturalization
4. PLACE OF BIRTH TAGUDIN, ILOCOS SUR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS #56
Widowed Separated House/Block/Lot No. Street
BIO
Other/s:
Subdivision/Village Barangay

7. HEIGHT (m) 1.67 TAGUDIN ILOCOS SUR

City/Municipality Province
8. WEIGHT (kg) 58.8 ZIP CODE 2714

9. BLOOD TYPE B+
18. PERMANENT ADDRESS #56
House/Block/Lot No. Street

10. GSIS ID NO. BIO

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1212-4608-1348 TAGUDIN ILOCOS SUR

City/Municipality Province

12. PHILHEALTH NO. ZIP CODE 2714

13. SSS NO. 0128938384 19. TELEPHONE NO.

14. TIN NO. 740-236-397-000 20. MOBILE NO. 0956-7304-966

15. AGENCY EMPLOYEE NO. 21. E-MAIL ADDRESS (if any) kathleenanneleal@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME

MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME LEAL

NAME EXTENSION (JR., SR)
FIRST NAME MANOLITO

MIDDLE NAME ALAMID

25. MOTHER'S MAIDEN NAME

SURNAME LEGASPI

FIRST NAME YOLANDA

MIDDLE NAME (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY SAINT AUGUSTINE'S SCHOOL PRIMARY EDUCATION 2004 2011 2011

VOCATIONAL
SECONDARY / SAINT AUGUSTINE'S SCHOOL HIGH SCHOOL 2011 2014 2014

TRADE
COLLEGE
COURSE SAINT LOUIS UNIVERSITY BACHELOR OF SCIENCE IN NURSING 2014 2018 2018

GRADUATE STUDIES

(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

PHILIPPINE NURSING LICENSURE EXAM 11/17-18/2018 BAGUIO CITY 0919141 5/8/2021

(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
28. INCLUSIVE DATES SALARY/ JOB/ PAY SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(mm/dd/yyyy) MONTHLY STATUS OF
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)
ILOCOS SUR DISTRICT HOSPITAL -
3/4/2019 PRESENT NURSE 6,600.00 JOB ORDER Y
TAGUDIN

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

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

Basic Life Support and Advanced Cardiac Life Support 1/11/2020 1/14/2020 32 MEDIC CENTRAL TRAINING CENTER

Blood borne Pathogens 12/19/2019 12/19/2019 AMERICAN SAFETY AND HEALTH INSTITUTE

Phlebotomy and Basic Intravenous Therapy Training 11/23/2019 11/26/2019 32 MEDIC CENTRAL TRAINING CENTER

ILOCOS SUR PROVINCIAL HOSPITAL GABRIELA

Basic Life Support and First Aid Management Training 6/17/2019 6/19/2019
SILANG

(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)

BASIC COMPUTER SKILLS PHILIPPINE NURSES ASSOCIATION

READING

WATCHING MOVIES

(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 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 ✘ 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 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
Rommel S. Lorenzana TAGUDIN, ILOCOS SUR 0956-9649-342 3.5 cm. X 4.5 cm
(passport size)
Juliet V. Bacbac BAGUIO CITY 0917-6585-162
With full and handwritten
Mary Rose D. Valenzuela BAGUIO CITY 0922-3640-404 name tag and signature over
printed name
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is a true, correct and
Computer generated
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the or photocopied picture
Philippines. I authorize the agency head/authorized representative to verify/validate the contents stated herein. is not acceptable
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/License/Passport No.: 0910141 Signature (Sign inside the box)

Date/Place of Issuance: 12/17/2019 - BAGUIO 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