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
Tr 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 us
an
I.sf PERSONAL INFORMATION
or
mi2. SURNAME INTRINA
ng
Se FIRST NAME IMMACULADA NAME EXTENSION (JR., SR)
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In MIDDLE NAME
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pp3. DATE OF BIRTH
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le (mm/dd/yyyy) 09/20/1979 16. CITIZENSHIP
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✘ Filipino Dual Citizenship
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by birth by naturalization
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DAVAO CITY If holder of dual citizenship, Pls. indicate country:
Int
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ar
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Sc5. SEX
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6 CIVIL STATUS
Single ✘ Married 17. RESIDENTIAL ADDRESS # 71 WEST SQUARE
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Sustainable Development Goals June 19, 2020 2 Technical Department of Education/UNDP

EmpSPOUSE'S SURNAME INTRINA Abiva Publishing House DATE OF BIRTH (mm/dd/

1 Adamson University Continuing Professional
Han FIRST NAME MARLEON Development Department 10/1/2009
SHEKINAH SAGE GRACE A. INTRINA
Free MIDDLE NAME BACUS 4/4/2016
Department of Education Region XI
TheOCCUPATION UNEMPLOYED 12/7/2017

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME ABO

NAME EXTENSION (JR., SR)
FIRST NAME EVARISTO SR.

MIDDLE NAME MUSTERA

25. MOTHER'S MAIDEN NAME

SURNAME BAHAN

FIRST NAME REMEDIOS

MIDDLE NAME QUETA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY WIRELESS ELEMENTARY SCHOOL HIGH SCHOOL 1986 1992 1992

SECONDARY
VOCATIONAL / DAVAO CITY NATIONAL HIGH SCHOOL 1992 1996 1996
*TEACHERS CERTIFICATE FOR NON TEACHING
PROFESSIONALS *BS IN
ACCOUNTANCY *BS IN
TRADE UNIVERSITY OF SOUTHEASTERN PHILIPPINES PUBLIC ADMINISTRATION 2013 2014 2014
COURSE MASTER OF EDUCATION MAJOR IN
COLLEGE HOLY CROSS 2003 2007
EDUCATIONAL MANAGEMENT 2007
OF DAVAO COLLEGE UNIVERSITY OF SOUTHEASTERN 2000
PHILIPPINES 2000
1996
GRADUATE STUDIES UNIVERSITY OF SOUTHEASTERN PHILIPPINES 2014 2014 12 UNITS
(Continue on separate sheet if necessary)

SIGNATURE DATE
CS FORM 212 (Revised 2017), Pa
AL DATA SHEET
ience Sheet shall cause the filing of administrative/criminal case/s against the person concerned.

EFORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

by naturalization
Pls. indicate country:

WEST SQUARE
Street

Barangay
Davao Del Sur
Province
Vibal Group

SPEHMPCO Alley, San Pedro Extension

5
Brgy. 6-A
Barangay
Davao Del Sur
Province

Department of Education

Vibal Group

Vibal Group

DATE OF BIRTH (mm/dd/yyyy)

10/1/2009

4/4/2016

12/7/2017

(Continue on separate sheet if necessary)

SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED
 SCHOLARSHIP/
ACADEMIC
HONORS
RECEIVED

WITH
HONORS

e on separate sheet if necessary)

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

LICENSURE EXAMINATION FOR TEACHER 79.0 1/26/2014 University of Mindanao Matina Campus 1290172 9/20/2021

(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
applicable)& STEP
STATUS OF
SALARY (Format "00-0")/ APPOINTMENT
INCREMENT
From To (Write in full/Do not abbreviate) (Write in full/Do not abbreviate)
Transformin (Y/ N)
g Self-
7/1/2019
Learning PRESENT Teacher I DepEd- Erico T. Nograles National High School 20,437.00 11-2 Permanent Y
Modules Into
Scripts for
Supplementa
Radio-Based
6/1/2019 Teacher I 3.5 20,179.00 11-1 Permanent
ry Learning
Instruction
"Creating
Materials in 12,000/
Through
Engaging 03/23/2016 Instructor 1.5 Job Order N
the Fourth
School-On- subject
Lessons
Innovations
Industrial
Air Format
through the
in Teaching
Revolution 9/23/2015 Substitute Teacher 1.5 18,549.00 Substitute Y
Use
and of
Supplementa
Learning:
lUtilizing
Resource 10/19/2014 General Instructor 1.5 8,000.00 Contractual N
Philippine
Materials"
Electronic
Art in Times
Materials in
Designing
of Crisis 10/1/2009 Accounting Assistant 1.5 8,500.00 Contractual N
Virtual
Instructional
(New
Classes Now
Materials
Edition)
Using
Super TV and 1/6/2006 Bookkeeper 1.5 2,000.00 Contractual N
Radio as
Schools
Teaching
Platforms
Series: Best in
Beyond
Teaching of 1.5
Practices
Subjects:
Moreh
Tapping
Capacitating
Academy 1.5
Connections
Teachers in
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the Use of
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Areas
in Teaching
Educational
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and Radio
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Conceptualiz
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Education 6
ation, Use 2020 June 25, 2020
Reimagined
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Webinar
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Sessions
Online June 22,
About
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Photoshop
TinkerCard
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Super
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Schools
Utilizing
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Series:and
Local Best
Practices of
Goveernmen 1.5
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TV and
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School 1.5
Broadcasting
in Enhancing
Sustainable
Students
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Empowering
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the Family to
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School Come
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Money in the
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New Normal
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Modality of
Teaching
 (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

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
ATTENDANCE Type of LD CONDUCTED/ SPONSORED BY
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS NUMBER OF ( Managerial/
(mm/dd/yyyy) HOURS Supervisory/
Technical/etc)
(Write in full) From To (Write in full)

Transforming Self-Learning Modules Into Scripts for Radio-Based Instruction

Through School-On-Air Format July 3, 2020 3.5 Technical DICT/UP College Diliman

Supplementary Learning Materials in the Fourth Industrial Revolution Jul 1, 2020 1.5 Technical Vibal Group

"Creating Engaging Lessons through the Use of Supplemental Resource Materials" June 30, 2020 1.5 Technical Vibal Group
Innovations in Teaching and Learning: Utilizing Electronic Materials in Virtual
Classes June 29, 2020 1.5 Technical Vibal Group

Philippine Art in Times of Crisis (New Now Edition) June 29, 2020 1.5 Technical Vibal Group

Designing Instructional Materials Using TV and Radio as Platforms in Teaching June 26, 2020 1.5 Technical Vibal Group

Super Schools Series: Best Practices of Moreh Academy June 26, 2020 1.5 Technical Vibal Group

Teaching Beyond Subjects: Tapping Connections among Learning Areas June 26, 2020 1.5 Teachnical
Vibal Group

Capacitating Teachers in the Use of Radio and TV in Teaching Basic Education June 25, 2020 1.5 Technical Vibal Group

Use of Educational Television and Radio Shows in Teaching June 24, 2020 1.5 Technical Vibal Group

Educational Disrupted Education Reimagined Part II June 23, 2020 June 25, 2020 6 Teachnical WISE Qatar Foundation

Conceptualization, Use and Creation of Self-made Videos for Online Teaching June 23, 2020 1.5 Technical Vibal Group

Webinar Sessions About Adobe Photoshop Essentials June 22, 2020 June 23, 2020 12 Technical Department of Education

TinkerCard 3D Development June 22, 2020 June 23, 2020 12 Technical Department of Education

Super Schools Series: Best Practices of Shekinah Learning School June 22, 2020 1.5 Technical Vibal Group

Utilizing Local and Goveernment TV and Radio Broadcasting in Enhancing Students

June 22, 2020 1.5 Technical Vibal Group
Competencies

Sustainable Development Goals June 19, 2020 2.0 Technical Department of Education/UNDP

Empowering the Family to Make the School Come to Life in Every Home June 19, 2020 1.0 Technical Abiva Publishing House

Adamson University Continuing

Handling Your Hard-Earned Money in the New Normal June 18, 2020 1.0 Technical
Professional Development Department

Free Wi-Fi Internet Access in Public Places Project June 18, 2020 2.0 Technical Department of Education/UNDP

The New Normal Classroom Modality of Teaching June 17, 2020 June 19, 2020 18.0 Technical Department of Education Region XI

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN
31. SPECIAL SKILLS and HOBBIES 32. 33.
ASSOCIATION/ORGANIZATION
(Write in full) (Write in full)

BOOKKEEPING SKILLS N/A N/A

COMPUTER OPERATION SKILLS N/A N/A

LEADERSHIP SKILLS N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE July 6, 2020

CS FORM 212 (Revised 2017), Page 3 of 4
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41. REFERENCES (Person not related by consanguinity or affinity to applicant /appointee)

NAME ADDRESS TEL. NO.

ID picture taken within
Erico T. Nograles the last 6 months
Jocelyn Simafranca National High 0943-394-2625 3.5 cm. X 4.5 cm
School
Baracatan (passport size)

Danilo P. Mondoyo National High 939391179312 With full and handwritten

School of
University
name tag and signature over
printed name
Eliza Braganza Southeastern 09196262724
Philippines Computer generated
42. I declare under oath that I have personally accomplished this Personal Data Sheet which is or photocopied picture
is not acceptable
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 PHOTO
misrepresentation made in this document and its attachments shall cause the 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: PRC
 ID/License/Passport No.: 1290172
Signature (Sign inside the box)

Date/Place of Issuance: August 22, 2014/DAVAO 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