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 MAÑACAP
NAME EXTENSION (JR., SR)
FIRST NAME RISCHELL

MIDDLE NAME SIMBAHAN

3. DATE OF BIRTH
5/13/1995 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH SAN PASCUAL, BATANGAS If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS
✘ Single Married 17. RESIDENTIAL ADDRESS 097
House/Block/Lot No. Street
Separat
Widowed GELERANG KAWAYAN
Other/s: ed Subdivision/Village Barangay
SAN PASCUAL BATANGAS
7. HEIGHT (m) 157cm
City/Municipality Province
8. WEIGHT (kg) 58kg ZIP CODE 4204

18. PERMANENT ADDRESS 097

9. BLOOD TYPE B POSITIVE
House/Block/Lot No. Street
GELERANG KAWAYAN
10. GSIS ID NO. N/A
Subdivision/Village Barangay
SAN PASCUAL BATANGAS
11. PAG-IBIG ID NO. N/A
City/Municipality Province

12. PHILHEALTH NO. 090504652504 ZIP CODE 4204

13. SSS NO. 04-3665500-3 19. TELEPHONE NO. 043-741-8063

14. TIN NO. 324-339-963 20. MOBILE NO. +63-977-0971-705

15. AGENCY EMPLOYEE NO. 2015445 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) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) N/A
FIRST NAME N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME MAÑACAP

NAME EXTENSION (JR., SR)
FIRST NAME ROLANDO

MIDDLE NAME SABUNG

25. MOTHER'S MAIDEN NAME

SURNAME SIMBAHAN

FIRST NAME MARIA

MIDDLE NAME ALISWAG (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY GELERANG KAWAYAN ELEMENTARY SCHOOL ELEMENTARY GRADUATE 2007

SECONDARY /
VOCATIONAL STA.TERESA COLLEGE HIGH SCHOOL GRADUATE 2011

N/A

TRADE
LYCEUM OF THE PHILIPPINES UNIVERSITY- BACHELOR OF SCIENCE IN MEDICAL
COURSE
COLLEGE
BATANGAS LABORATORY SCIENCE 2015

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
09/12/2015 to
PRC LICENSE 83.1 09/13/2015
MARY CHILES COLLEGE 0073726 5/13/2022

(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.
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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
Our Lady of Caysasay Medical Center
10/3/2015 6/14/2020 MEDICAL TECHNOLOGIST 14000.00 Regular No
(Laboratory Department)
6/15/2020 9/15/2020 MEDICAL TECHNOLOGIST Batangas Medical Center 32053.00 Contractual Yes

(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
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
BioRisk Association of the Philippines 2015, Inc. (BRAP
What's Under Your Hood? An In-depth Discussion on Biosafety Cabinets 6/11/2020 6/11/2020 2.5 Technical 2015) & Philippine Association of Medical Technologists,
Inc. (PAMET)
The Role of Laboratory during COVID-19 Pandemic: The Shared Experience 6/6/2020 6/6/2020 2.5 Technical Malaysian Institute of Medical Laboratory Sciences

BIORISK MANAGEMENT TRAINING 5/28/2020 5/29/2020 16.0 Technical Batangas Medical Center
BioRisk Association of the Philippines 2015, Inc. (BRAP
BRAP-PAMET International Webinar on Essential Biosafety for COVID-19 5/28/2020 5/28/2020 2.0 Technical 2015) & Philippine Association of Medical Technologists,
Inc. (PAMET)
National Training Center for Biosafety and Biosecurity,
Biosafety Education and Awareness Training Against COVID-19 5/25/2020 5/26/2020 16.0 Technical National Institutes of Health, University of the
Philippines-Manila
Enhancing the Competencies of Medical Technologists on Quality RT-PCR Testing for COVID-19 Philippine Association of Medical Technologists, Inc.
5/25/2020 5/25.2020 2.0 Technical
(Session 2) (PAMET)
Enhancing the Competencies of Medical Technologists on Quality RT-PCR Testing for COVID-19 Philippine Association of Medical Technologists, Inc.
5/23/2020 5/23/2020 2.0 Technical
(Session 1) (PAMET)

Biosafetty and Biosecurity Considerations for COVID-19 Testing on Resource Limited Settings 5/13/ 2020 5/13/2020 2.0 Technical University of Santo Tomas

AACC Learning Lab for Laboratory Medicine on Nejim

Coronovirus Disease 2019 3/30/2020 3/30/2020 2.0 Technical
Knowledge+
Our Lady of Caysasay Medical Center(Safety & Risk
PERSONALITY WORKSHOP 11/29/2019 11/29/2019 5.0 Technical
Management)
OUR LADY OF CAYSASAY MEDICAL
MANDATORYY 8 HOUR SAFETY AND HEALTH SEMINAR FOR WORKERS 11/22/2019 11/22/1019 8.0 Technical
CENTER( SAFETY&RISK MNGT.)

CPR READY FILIPINO FAMILIES 7/17/2019 7/17/2019 5.0 Technical

FDM Training Center
Our Lady of Caysasay Medical Center(Safety & Risk
EMERGENCY & DISASTER PREPAREDNESS TRAINING 5/21/2019 5/21/2019 8.0 Technical
Management)

2017 3RD QUARTERLY CONTINUING PROFESSIONAL DEVELOPMENT SYMPOSIUM 9/30/2017 0/30/2017 8.0 Technical
PAMET BATANGAS CHAPTER
(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)
PHILIPPINE ASSOCIATION OF MEDICAL
PAMET
TECHNOLOGISTS(PAMET)

(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 ✘

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
ARISTOTLE PETER LEE,MD DPSP V.ILLUSTRE AVE. LEMERY, BATANGAS 9255626268 4.5 cm. X 3.5 cm
(passport size)

FABIANA GELNDA AGONCILLO,RMT V.ILLUSTRE AVE. LEMERY, BATANGAS 9179958910

Computer generated
or photocopied picture
OLIVER SHANE DUMAOAL,RMT,MSMT,CBO CAPITOL SITE BATANGAS CITY 437233043 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:

ID/License/Passport No.: 0073726

Signature (Sign inside the box)

Date/Place of Issuance: 05/16/2016-PRC MANILA

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