CS Form No.

212

PERSONAL DATA SHEET

Revised 2017

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 NARAG
NAME EXTENSION (JR., SR)
FIRST NAME CRISTINA N/A
MIDDLE NAME PABLO
3. DATE OF BIRTH
03/10/1989 16. CITIZENSHIP Filipino Dual Citizenship
(mm/dd/yyyy)
by birth by naturalization
4. PLACE OF BIRTH Santiago City If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male Female

6 CIVIL STATUS Single Married 17. RESIDENTIAL ADDRESS 27 Mayon Extension

Widowed Separated House/Block/Lot No. Street

Other/s:
N/A San Gabriel Village
Subdivision/Village Barangay

7. HEIGHT (m) 1.63 Tuguegarao Cagayan

City/Municipality Province
8. WEIGHT (kg) 80 ZIP CODE 3500

9. BLOOD TYPE 18. PERMANENT ADDRESS 27 Mayon Extension

O
House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A San Gabriel Village

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1211-5255-6061 Tuguegarao Cagayan

City/Municipality Province

12. PHILHEALTH NO. 06-025171117-0 ZIP CODE 3500

13. SSS NO. 01-2224889-2 19. TELEPHONE NO. (078) 375-1859

14. TIN NO. 473-789-670-000 20. MOBILE NO. 09778104587

15. AGENCY EMPLOYEE NO. 223 21. E-MAIL ADDRESS (if any) tenpablo@yahoo.com.ph
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME NARAG 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME CESAR CZARINNA MAE P. NARAG 02/03/2009
N/A

MIDDLE NAME TOMAS CZIAH KIRSTEN P. NARAG 04/04/2019

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME PABLO

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

MIDDLE NAME DE GUZMAN

25. MOTHER'S MAIDEN NAME

SURNAME LEONORA
FIRST NAME DELPINADO
MIDDLE NAME SANTOS (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY Santiago South Central School Primary 1995 2001 Graduated 2001 N/A

SECONDARY University of La Salette High School Secondary 2001 2005 Graduated 2005 N/A
VOCATIONAL /
TRADE COURSE
N/A N/A N/A N/A N/A N/A N/A

COLLEGE University of La Salette Bachelor of Science in Nursing 2005 2010 Graduated 2010 N/A
Earning Units in Education Major in
EARNING UNITS University of Cagayan Valley 2014 2015 Graduated 2015 N/A
Biological Science
Saint Paul University Philippines, Tuguegarao,
GRADUATE STUDIES Master of Science in Nursing 2015 2017 Graduated 2017 N/A
Cagayan
(Continue on separate sheet if necessary)

SIGNATURE DATE January 25, 2021

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 Date of
(If Applicable) NUMBER
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT Validity

RA 1080 (NURSE) 75 July 2010 Tuguegarao 0650213 10/03/2022

RA 1080 (TEACHER) 76.40 March 2017 Tuguegarao 1540646 03/10/2020

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

10/10/2015 Present Senior Staff Nurse Divine Mercy Wellness Center 17,995 Permanent No

(Continue on separate sheet if necessary)

SIGNATURE DATE January 25, 2021

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S
NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES
29.
(Write in full) (mm/dd/yyyy) NUMBER OF HOURS POSITION / NATURE OF WORK
From To

(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 Type of LD

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

- Safe Handling of Hazardous Drugs Seminar 06/26/2019 06/26/2019 8 Technical Biosafety Institute

- Clinical Practicum for MSN Adult Health Nursing 08/07/2017 08/26/2017 200 Technical Perpetual Succour Hospital of Cebu, Inc.

Training on Rational Blood Use and Hospital Blood Transfusion

- 08/04/2017 08/04/2017 8 Technical Department of Health RO2
Committee Workshop

- Personality Development Enhancement Seminar 04/28/2016 04/28/2016 8 Technical Divine Mercy Wellness Center

Update on “Advanced Care in Infusion Theraphy” “IV Theraphy Association of Nursing Service
- 11/12/2015 11/14/2015 24 Technical
Documentation” “Standards of Professional Care in IV Theraphy” Administrators of the Philippines

- Hypertension Peak – A symposium on Hypertension 11/06/2015 11/06/2015 8 Technical Philippine Heart Association

ASHI (American Safety and Health

- Basic Life Support – CPR Pro for the Professional Rescuer 08/12/2015 08/12/2015 8 Technical
Institute)
ASHI (American Safety and Health
- Advanced Cardiac Life Support 08/11/2015 08/11/2015 8 Technical
Institute)
- BLS - ACLS 06/26/2012 06/28/2012 24 Technical Philippine Heart Center

- Basic ECG and Arrhythmia Recognition Course 06/25/2012 06/25/2012 8 Technical Philippine Heart Center

- 3-Day Basic Intravenous Therapy Training 03/01/2015 03/03/2015 24 Technical Cagayan Valley Medical Center

The Primary Respiratory Health Care Center of the Philippines an

- 02/13/2010 02/13/2010 8 Technical The Lung Center of the Philippines
Overview

- Respiratory Clients Care Updates Identified and Enhanced 02/13/2010 02/13/2010 8 Technical The Lung Center of the Philippines

“Knowing Thyself by Delving Deeper into Personality Disorders and

- 01/26/2010 01/26/2010 8 Technical University of La Salette
Acquainting One’s Self to Sexual Disorders”

“Boosting Confidence and Competence Through Professional

- 01/26/2010 01/26/2010 8 Technical University of La Salette
Power Dressing”

“Enhancing Nurses Efficiency of Care Through Understanding and

- 01/13/2010 01/13/2010 8 Technical University of La Salette
Developing One’s Personality”

- “Perspective and Diagnosis of Coronary Artery Disease” 01/12/2010 01/12/2010 8 Technical University of La Salette

- “Wastong Nutrisyon Kailangan, lifestyle Diseases Iwasan” 07/29/2009 07/29/2009 8 Technical University of La Salette

- OR Team, Maintaining The Right Track 12/12/2007 12/12/2007 8 Technical University of La Salette

- Basic Life Support: Adult Cardiopulmonary Resuscitation 04/14/2007 04/14/2007 8 Technical The Philippine National Red Cross

- “First Aid Training” 04/12/2007 04/13/2007 16 Technical The Philippine National Red Cross

“Effective Speech Communication Stategies for the Global

- 10/03/2006 10/03/2006 8 Technical University of La Salette
Competitiveness”

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

Computer Operations N/A Philippine Nurses Association

Critical Thinking and problem solving Association of Nursing Service Administrators

Patient Safety of the Philippines

Leadership
(Continue on separate sheet if necessary)

SIGNATURE DATE January 25, 2021

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 by YES NO
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 out If YES, give details:
(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
(078)844-4624/ the last 6 months
Taytana Tulauan, RN, MSN - Chief Nurse Divine Mercy Wellness Center 3.5 cm. X 4.5 cm
09353638379 (passport size)
(078)844-4624/
Blizette Z. Razon, RN - Head Nurse Divine Mercy Wellness Center With full and handwritten
09154164933 name tag and signature over
(078)844-4624/ printed name
Cynthia Zingapan, RN, MSN - Nurse Supervisor Divine Mercy Wellness Center
09756865149
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 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.: 0650213

Signature (Sign inside the box)

Tuguegarao City
January 25, 2021
Date/Place of Issuance:
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