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 QUINLOG
NAME EXTENSION (JR., SR) N/A
FIRST NAME RODULFO

MIDDLE NAME DOYDORA

3. DATE OF BIRTH
(mm/dd/yyyy) 01/12/1957 16. CITIZENSHIP
✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH ALICIA, BOHOL If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX ✘ Male Female

6 CIVIL STATUS Single ✘ Married 17. RESIDENTIAL ADDRESS B9 Lot 17 Phase E

Widowed Separate House/Block/Lot No. Street
d Francisco Homes Mulawin
Other/s:
Subdivision/Village Barangay
San Jose Del Monte City Bulacan
7. HEIGHT (m) 1.57m
City/Municipality Province
8. WEIGHT (kg) 62kg ZIP CODE 3023

18. PERMANENT ADDRESS B9 Lot 17 Phase E

9. BLOOD TYPE ''o''
House/Block/Lot No. Street
francisco homes mulawin
10. GSIS ID NO. B57ACRDQ13
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 0007-579497-07 san jose del monte city bulacan
City/Municipality Province

12. PHILHEALTH NO. 19-000191861-7 ZIP CODE 3023

13. SSS NO. 03-7085429-0 19. TELEPHONE NO. n/a

14. TIN NO. 109-861-808 20. MOBILE NO. 09468279718

15. AGENCY EMPLOYEE NO. 715 21. E-MAIL ADDRESS (if any) [email protected]

II. FAMILY BACKGROUND

22. SPOUSE'S SURNAME QUINLOG 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME SIMEONA

NAME EXTENSION (JR., SR) IRISH U. QUINLOG 11/25/1995

MIDDLE NAME URRIZA

OCCUPATION n/a

EMPLOYER/BUSINESS NAME n/a

BUSINESS ADDRESS n/a

TELEPHONE NO.

24. FATHER'S SURNAME QUINLOG[Deceased]

NAME EXTENSION (JR., SR)
FIRST NAME MARGARITO

MIDDLE NAME BOYLES

25. MOTHER'S MAIDEN NAME

SURNAME DOYDORA [Deceased]

FIRST NAME ANA

MIDDLE NAME CUSO (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY ALICIA ELEMENTARY FARM SCHOOL PRIMARY 1964 1976 1976

SECONDARY ALICIA BARANGAY HIGH SCHOOL HIGH SCHOOL 1976 1980 1980

VOCATIONAL / TRADE n/a

COURSE

COLLEGE n/a

GRADUATE STUDIES n/a

(Continue on separate sheet if necessary)

SIGNATURE DATE January 22, 2019

CS FORM 212 (Revised 2017), Page 1 of 4

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

n/a n/a n/a n/a n/a n/a

(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
(mm/dd/yyyy) POSITION TITLE DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY GRADE (if 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)

6/22/2018 PRESENT Nursing Attendant II Philippine Heart Center P15,066.00 06 - Permanent Yes

02/01/2017 6/21/2018 Storekeeper II Philippine Heart Center P14,474.00 06 - Permanent Yes

03/01/2016 1/31/2017 Storekeeper II Philippine Heart Center P14,020.00 06 - Permanent Yes

08/03/2005 2/28/2016 Storekeeper II Philippine Heart Center P12,462.00 06 - Permanent Yes

08/03/2002 08/02/2005 Storekeeper II Philippine Heart Center P7,796.00 06 - Permanent Yes

07/01/2001 08/02/2002 Storekeeper II Philippine Heart Center P7,606.00 06 - Permanent Yes

01/01/2000 06/30/2001 Storekeeper II Philippine Heart Center P7,244.00 06 - Permanent Yes

08/03/1999 12/31/1999 Storekeeper II Philippine Heart Center P6,585.00 06 - Permanent Yes

01/01/1999 08/02/1999 Storekeeper I Philippine Heart Center P6,388.00 04 - Permanent Yes

11/01/1997 12/31/1996 Storekeeper I Philippine Heart Center P6,232.00 04 - Permanent Yes

01/01/1997 10/31/1997 Storekeeper I Philippine Heart Center P5,941.00 04 - Permanent Yes

01/01/1996 12/31/1996 Storekeeper I Philippine Heart Center P5,141.00 04 - Permanent Yes

01/01/1995 12/31/1995 Storekeeper I Philippine Heart Center P4,118.00 04 - Permanent Yes

01/01/1994 12/31/1994 Storekeeper I Philippine Heart Center P3,118.00 04 - Permanent Yes

06/03/1993 12/31/1993 Storekeeper I Philippine Heart Center P2,318.00 04 - Permanent Yes

01/01/1992 12/31/1992 Storekeeper I Philippine Heart Center P2,295.00 04 - Permanent Yes

01/01/1990 12/31/1991 Storekeeper I Philippine Heart Center P2,272.00 04 - Permanent Yes

07/01/1989 12/31/1989 Storekeeper I Philippine Heart Center P2,250.00 04 - Permanent Yes

01/01/1989 06/30/1989 Linen Attendant Philippine Heart Center P916.00 03 - Permanent Yes

01/01/1988 12/31/1988 Linen Attendant Philippine Heart Center P763.00 03 - Permanent Yes

07/01/1987 12/31/1987 Linen Attendant Philippine Heart Center P634.00 03 - Permanent Yes

01/01/1987 06/30/1987 Linen Attendant Philippine Heart Center P603.00 03 - Permanent Yes

06/09/1986 12/31/1986 Nursing Attendant Philippine Heart Center P520.00 03 - Permanent Yes

(Continue on separate sheet if necessary)

SIGNATURE DATE January 22, 2019

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

URBAN GARDENING 9/27/2018 9/27/2018 4 HOURS technical PHILIPPINE HEART CENTER

HYPERTENSION & NUTRITION MANAGEMENT 7/5/2018 7/5/2018 3 HOURS technical PHILIPPINE HEART CENTER

WOMEN AND THE ENVIRONMENT: TOXIC FREE FUTURE 3/31/2017 3/31/2017 3 HOURS technical PHILIPPINE HEART CENTER

ANG KABABAIHAN NG MALOLOS 3/30/2017 3/30/2017 3 HOURS technical PHILIPPINE HEART CENTER

GOVERNANCE IN HEALTHCARE: PERFORMANCE GOVERNANCE SYSTEM MODULE 1 1/11-13/2017 1/11-13/2017 24 HOURS SUPERVISORY PHILIPPINE HEART CENTER

INFECTION CONTROL SCIENTIFIC SYMPOSIUM – BREAK THE CHAIN OF INFECTION 10/20/2016 10/20/2016 8 HOURS technical PHILIPPINE HEART CENTER

RULES ON ADMINISTRATIVE CASES AND PENALTIES 9/21/2016 9/21/2016 4 HOURS technical PHILIPPINE HEART CENTER

GETTING TO KNOW HIV/AIDS IN THE WORKPLACE 8/28/2016 8/28/2016 4 HOURS technical PHILIPPINE HEART CENTER

1st JOINT SUMMIT ON: GOVERNANCE IN HEALTHCARE 7/13-15/2016 7/13-15/2016 24 HOURS SUPERVISORY PHILIPPINE HEART CENTER

THE ESSENTIALS OF GOOD PUBLIC MANAGEMENT 4/3/2017 4/3/2017 8 HOURS SUPERVISORY PHILLIPPINE HEART CENTER

EMOTIONAL QUOTIENT IN THE WORKPLACE 2/11/2016 2/11/2016 8 HOURS technical PHILIPPINE HEART CENTER

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

MASONDRY 30 YEARS SERVICE AWARDEE 2017 Nursing Service Employee of the Phillipine
Heart Center
Phillipine Heart Center Employees Association
PLAYING BILLIARD 25 YEARS SERVICE AWARDEE 2012 Alliance of Health Workers

20 YEARS SERVICE AWARDEE 2017 Phillipine Heart Center Development Cooperative

15 YEARS SERVICE AWARDEE 2002

10 YEARS SERVICE AWARDEE 1997

5 YEARS SERVICE AWARDEE 1992

(Continue on separate sheet if necessary)

SIGNATURE DATE January 22, 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 ✘

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
by any court or tribunal? YES ✘ NO
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
Barangay election)? YES ✘ NO
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

JOCELYN DISPO FORTIN LINEN SECTION PHILIPPINE HEART 925-2401

the last 6 months
CENTER 3.5 cm. X 4.5 cm
(passport size)

EMERSON DERIS LINEN SECTION PHILIPPINE HEART 925-24-01

CENTER With full and handwritten
name tag and signature over
LINEN SECTION PHILIPPINE HEART printed name
EDGARDO BARGOLA CENTER 925-2401
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
complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the is not acceptable
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
administrative/criminal case/s against me. PHOTO

Government Issued ID (i.e.Passport, GSIS, SSS, PRC, Driver's License, etc.)

PLEASE INDICATE ID Number and Date of
Issuance

Government Issued ID: GSIS UMID CARD

ID/License/Passport No.: CRN 006-0061-3901-8

Signature (Sign inside the box)
01/22/2019
Date/Place of Issuance: 01/2018
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