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 Maglinte
NAME EXTENSION (JR., SR)
FIRST NAME Rene Lee
MIDDLE NAME Madulara
3. DATE OF BIRTH
(mm/dd/yyyy) Dec. 12,1983 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH Pili, Siquijor, Siquijor If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

Single ✘ Married 17. RESIDENTIAL ADDRESS

6 CIVIL STATUS
Widowed Separate House/Block/Lot No. Street
d
Other/s:

Subdivision/Village Luyang

7. HEIGHT (m) 5'3"

Siquijor Siquijor
8. WEIGHT (kg) 67kg ZIP CODE 6225
9. BLOOD TYPE B+ 18. PERMANENT ADDRESS
House/Block/Lot No. Street
10. GSIS ID NO.
Subdivision/Village Luyang
11. PAG-IBIG ID NO.
121087797822
Siquijor Siquijor
12. PHILHEALTH NO. 120253097510 ZIP CODE 6225
13. SSS NO. 0728461837 19. TELEPHONE NO.

14. TIN NO. 436-091-464-00 20. MOBILE NO. 09568509130

15. AGENCY EMPLOYEE NO. IPHO-104 21. E-MAIL ADDRESS (if any) [email protected]
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Maglinte 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME Loudwin Mae Draque Lestat G. Maglinte 7/15/2009
MIDDLE NAME Geguerra
OCCUPATION BPO Employee
EMPLOYER/BUSINESS NAME Qualfon Dumaguete
BUSINESS ADDRESS Dumaguete City
TELEPHONE NO.

24. FATHER'S SURNAME Maglinte

NAME EXTENSION (JR., SR)
FIRST NAME Leweline
MIDDLE NAME Abing
25. MIDDLE NAME

SURNAME Madulara
FIRST NAME Reneria
MIDDLE NAME Gumisad (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

First Honorable
ELEMENTARY Banban Elementary School Primary 1991 1997 1997 Mention

SECONDARY /
VOCATIONAL Siquijor State University Secondary 1997 2001 2001

TRADE
COURSE St. Paul University of Bachelor of Science in
COLLEGE 2001 2005 2005
Dumaguete Nursing
GRADUATE STUDIES

(Continue on separate sheet if necessary)

SIGNATURE DATE April 24, 2023

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

Nursing Licensure Examinition 77.00% Dec.3-4, 2005 University of Cebu 0394522 12/12/2022

(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 (mm/dd/yyyy)
SALARY/ JOB/ PAY GOV'T SERVICE
POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY GRADE (if
(Write in full/Do not (Write in MONTHLY SALARY applicable)& STEP STATUS OF APPOINTMENT
(Y/
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT N)
From To

4/1/2016 Present Operating/Delivery Nurse Siquijor Provincial Hospital 16,000.00 Contractual Yes

4/9/2013 3/31/2016 Ward Nurse Siquijor Provincial Hospital 8,000.00 Contractual Yes

8/1/2012 1/16/2013 Account Officer Lifebank Foundation, Inc. 7,000.00 Contractual No

Integrated Management System
5/15/2010 7/29/2012 Company Nurse 6,000.00 Contractual No
(IMS)
5/7/2008 3/30/2009 Volunteer Nurse Siquijor Provincial Hospital 0.00 Volunteer Yes
Silliman University Medical
10/1/2007 2/15/2008 Pediatric Nurse 7,000.00 Contractual No
Center(SUMC)

(Continue on separate sheet if necessary)

SIGNATURE DATE April 20, 2023

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

Knights of Columbus 2009 2022 12 First Degree Knight Member

Outreached Medical & Surgical Mission of the Philippines
4/22/2017 12 Operating Room Nurse
Obstetrical & Gynecological Society
Medical, Surgical, Dental,Optha- Mission (Fil-Am Charity Inc.
2/2/2017 2/4/2017 36 Operating Room Nurse
St. Louis, USA)

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
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 - Cardio Pulmonary Resuscitation Training of

9-26-2022- to 9-30-2022 40 technical DOH DRRM-H Trainers
Trainers
Standard First Aide Training 9-21-2023 to 9-23-2022 24 technical SPH SFA Trainer

Basi Life Support and Cardio Pulmonary Resuscitation Training 9-19-2022 to 9-20-2022 16 technical SPH BLS Trainer
Disaster Risk Reduction Management - Health (Health Emergency
9-8-2022 to 9-10-2022 24 technical DOH DRRM-H Trainers
Response Operation) Traning
System Approach to Medical Safety 4/30/2022 8.0 technical Philippine Nurses Association

Covid-19 Response & Donning- Doffing Orientation 12/13/2021 8.0 technical Siquijor Prvincial Hospital
Health for Older Adults Trends in Gerontology & Neurocognitive
4/6/2019 8.0 technical Philippine Nurses Association
Disorders

Infection Prevention & Control Caravan 8/26/2018 8.0 technical Philippine Nurses Association

Basic life Support Cardio Pulmonary Resuscitation for Healthcare 9/19/2016 9/20/2016 16.0 technical Health Emergency Management Staff

Siquijor Provincial Hospital BEmONC

Bask Emergency Obstetric & New Born Care (BEmONC) 11/5/2015 8.0 technical
Staff

(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)

Drawing & Arts Achievement Award for Arts Knights of Columbus

Certificate of appearance as facilitator Basic Life Support Cardio Pulmonary

Resuscitation Training

Outstanding contribution as a speaker for Drug Awareness & Pre- Marital Sex
information Dissemenation Campaign Phil-am Charities Inc of St. Louis USA

Certificate of appreciation for participation and support in the medical- surgical-

dental-optha mission

Certificate of appreciation in recognition of his exemplary and deicated service

during outreached, medical and surgical mission of Philippine Obstetrical and
gynecological society, Cebu Chapter
Certificate of appreciation foran outstanding dedication, performance and
positive attitude towards service at Siquijor Provincial Hospital

(Continue on separate sheet if necessary)

SIGNATURE DATE April 24, 2023
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? ________________________________
Resignation from work
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
Dr. George Walthrode L. Opay Sandugan, Larena Siquijor 9358582343 4.5 cm. X 3.5 cm
(passport size)

Board Member Brylle Deeiah Tumarong Candanay, Siquijor,Siquijor 9558611578

Computer generated
or photocopied picture
Leny B. Sulapas BS RN III Calalinan, Siquijor, Siquijor 9494302978 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 Licence
ID/License/Passport No.: 0394522 Signature (Sign inside the box)

Date/Place of Issuance: 03-23-2006/ Cebu 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