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.

I. PERSONAL INFORMATION
2. SURNAME PALEAN
NAME EXTENSION (JR., SR
FIRST NAME DANICA JOY
MIDDLE NAME VALLE
3. DATE OF BIRTH
(mm/dd/yyyy) 9/9/1994 16. CITIZENSHIP ✘ Filipino Dual Citizenship
✘ by birth by

4. PLACE OF BIRTH NAGA CITY If holder of dual citizenship, Pls. indicate cou
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS LOT 11 BLOCK 15
Widowed Separated House/Block/Lot No.
Other/s: RAMAIDA VILLAGE CONCEP
Subdivision/Village
7. HEIGHT (m) 152 m NAGA CITY CAMA
City/Municipality
8. WEIGHT (kg) 51 kg ZIP CODE 4400

9. BLOOD TYPE B+
18. PERMANENT ADDRESS LOT 11 BLOCK 15
House/Block/Lot No.

10. GSIS ID NO. RAMAIDA VILLAGE CONCEP

Subdivision/Village
NAGA CITY CAMA
11. PAG-IBIG ID NO. 1211-5997-7772
City/Municipality

12. PHILHEALTH NO. 10-050221127-1 ZIP CODE 4400

13. SSS NO. 05-1126542-8 19. TELEPHONE NO. N/A

14. TIN NO. 463-587-131-000 20. MOBILE NO. 09175003137/0961118682

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

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME PALEAN

NAME EXTENSION (JR., SR)
FIRST NAME DANILO

MIDDLE NAME MEJELLANO

25. MOTHER'S MAIDEN NAME VALLE

SURNAME PALEAN

FIRST NAME JUANA

MIDDLE NAME PEJO (Continue on separate sheet if necess

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 NAGA CENTRAL SCHOOL I 2003 2006

SECONDARY NAGA HOPE CHRISTIAN SCHOOL 2006 2010

COLLEGE UNIVERSITY OF NUEVA CACERES BACHELOR OF SCIENCE IN NURSING 2010 2014

GRADUATE STUDIES
(Continue on separate sheet if necessary)

SIGNATURE DATE 10/01/2019 CS FORM 212 (R

L DATA SHEET
ence Sheet shall cause the filing of administrative/criminal case/s against the person

FORE ACCOMPLISHING THE PDS FORM.

(Do not fill up. For CSC use only)

NAME EXTENSION (JR., SR)

Dual Citizenship

by naturalization

Pls. indicate country:

Street
CONCEPCION GRANDE
Barangay
CAMARINES SUR
Province
4400

Street
CONCEPCION GRANDE
Barangay
CAMARINES SUR
Province

4400

N/A

09175003137/09611186827

[email protected]

DATE OF BIRTH (mm/dd/yyyy)

(Continue on separate sheet if necessary)

YEAR SCHOLARSHIP/
GRADUATED ACADEMIC HONORS
RECEIVED

2006

2010
 2014

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 DATE OF LICENSE (if app
RATING
SPECIAL LAWS/ CES/ CSEE EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT

PHILIPPINE NURSING LICENSURE

75.6 5/30/2014 LEGAZPI CITY, PHILIPPINES 0833250
EXAMINATION

(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/ PAY
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

BICOL REGION GENERAL HOSPITAL AND

9/26/2019 PRESENT NURSE I PERMANENT
GERIATRIC MEDICAL CENTER
BICOL REGION GENERAL HOSPITAL AND CONTRACTUAL
6/17/2019 9/25/2019 NURSE I
GERIATRIC MEDICAL CENTER SERVICE

09/27/2017 PRESENT PER DIEM HEMODIALYSIS NURSE BICOL RENAL CARE CENTER PER DIEM

10/2/2017 6/15/2019 STAFF NURSE LIBMANAN DISTRICT HOSPITAL MOA

DR. NILO ROA MEMORIAL
11/1/2015 12/25/2016 HEMODIALYSIS STAFF NURSE PERMANENT
FOUNDATION HOSPITAL
EMERGENCY, OPERATING, DELIVERY DR. NILO ROA MEMORIAL
1/1/2015 10/31/2015 PERMANENT
ROOM STAFF NURSE FOUNDATION HOSPITAL
DR. NILO ROA MEMORIAL
1/11/2014 12/31/2014 WARD STAFF NURSE PERMANENT
FOUNDATION HOSPITAL
 (Continue on separate sheet if necessary)

SIGNATURE DATE 10/01/2019 CS FORM 212 (Revised 2017), P

 LICENSE (if applicable)

Date of
Validity

9/9/2020

ate sheet if necessary)

GOV'T SERVICE

(Y/
N)

N
ate 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 / 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
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
UPDATE AND BREAKTHROUGHS OF NURSING SCIENCE TO AMELIORATE
2/3/2019 2/3/2019 8 PROFESSIONAL UNIVERSIDAD DE STA. ISABEL-GRADUATE SCHOOL
VINCENTIAN REGISTERED NURSES TO BE GLOBALLY COMPETITIVE
INNOVPHIL (AHA)
ADVANCE CARDIOVASCULAR LIFE SUPPORT 08/20/2018 08/21/2018 12 PROFESSIONAL
ACADEMY OF EMERGNECY SCIENCES
INNOVPHIL (AHA) ACADEMY OF EMERGNECY
BASIC LIFE SUPPORT FOR HEALTHCARE PROVIDERS 08/18/2018 08/18/2018 8 PROFESSIONAL
SCIENCES
2ND PUBLIC HEALTH CONGRESS ON RENAL DISEASE CONTROL PROGRAM
06/22/2017 06/22/2017 8 PROFESSIONAL DEPARTMENT OF HEALTH
(REDCOP)

SEMINAR WORKSHOP ON VASCULAR ACCESS MANAGEMENT 9/4/2017 9/4/2017 8 PROFESSIONAL RENAL NURSE ASSOCIATION OF THE PHILIPPINES

LACTATION MANAGEMENT 1/3/2017 3/3/2017 20 PROFESSIONAL LIBMANAN DISTRICT HOSPITAL

1ST PUBLIC HEALTH CONGRESS ON RENAL DISEASE CONTROL PROGRAM

06/16/2016 06/16/2016 8 PROFESSIONAL DEPARTMENT OF HEALTH
(REDCOP)
BASIC OPERATION OF 4008S NEXT GENERATION HEMODIALYSIS MACHINE WITH
12/24/2015 12/24/2015 8 TECHNICAL FRESENIUS MEDICAL CARE
TROUBLESHOOTING
BASIC OPERATION OF 4008B HEMODIALYSIS MACHINE WITH
12/24/2015 12/24/2015 8 TECHNICAL FRESENIUS MEDICAL CARE
TROUBLESHOOTING

TRAINING IN THE NURSING CARE OF DIALYSIS PATIENTS 10/01/2015 02/15/2016 448 PROFESSIONAL DR. NILO ROA MEMORIAL FOUNDATION HOSPITAL

CLINICAL AND SONOLOGICAL UPDATES IN OB-GYN 11/12/2015 11/12/2015 8 TECHNICAL BICOL MEDICAL CENTER

MANAGEMENT OF PATIENT WITH HYPOTHYROIDISM AND HYPERTHYROIDISM 06/30/2015 06/30/2015 4 QUALITY DR. NILO ROA MEMORIAL FOUNDATION HOSPITAL

MANAGEMENT OF PATIENT WITH ECTOPIC PREGNANACY, ABRUPTIO PLACENTA

06/15/2015 06/15/2015 4 QUALITY DR. NILO ROA MEMORIAL FOUNDATION HOSPITAL
AND PLACENT PREVIA

RESPIRATORY DISORDER:ASTHMA 05/27/2015 05/27/2015 4 QUALITY DR. NILO ROA MEMORIAL FOUNDATION HOSPITAL

BASIC INTRAVENOUS THERAPY TRAINING COURSE 05/20/2015 05/22/2015 24 PROFESSIONAL BICOL MEDICAL CENTER

VIII. OTHER INFORMATION

NON-ACADEMIC DISTINCTIONS / RECOGNITION MEMBERSHIP IN ASSOCIATION/ORGANIZATION

31. SPECIAL SKILLS and HOBBIES 32. 33.
(Write in full) (Write in full)

RENAL NURSE ASSOCIATION OF THE

N/A N/A
PHILIPPINES - MEMBER

(Continue on separate sheet if necessary)

SIGNATURE DATE 10/01/2019 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 NO
YES ✘
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 YES ✘ NO
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?
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
KENNETH GUTIERREZ, MHA, RN NAGA CITY 9778426172 3.5 cm. X 4.5 cm
(passport size)

MARY KHRISTINE F. ADAN, RN NAGA CITY 9994852585 With full and handwritten
name tag and signature over
printed name
JOSEFINA CORTEZ, RN NAGA CITY 9152158063
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
Government Issued ID: PRC ID
ID/License/Passport No.: 0833250 Signature (Sign inside the box)
10/01/2019
Date/Place of Issuance: 05/09/2017/LEGAZPI 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