Republic of the Philippines

DEPARTMENT OF HEALTH 2x2 ID Photo

PRIMARY CARE WORKERS’ CERTIFICATION PROGRAM

APPLICATION FORM
APPLICANT’S PERSONAL INFORMATION
Name (Last Name, First Name, Middle Name) Suffix/ Extension Name Sex
☐Male
REMITAR, CHRISTINE ANNE MONOY ☐Female
Date of Birth (mm/dd/yyyy) Age Citizenship Civil Status
☐Filipino ☐Single ☐Widowed
09/20/1990 33 ☐Dual Citizenship; ☐Married ☐ Separated
Country:_________ ☐Others: ____________
Active Mobile Number Active Email Address
09517368308 Office Email: santo.nino10301@gmail.com Personal Email: jsmremitar326@gmail.com
Profession PRC License
NURSE Number: 0749099 Date of Issuance: 03/22/2012 Date of Expiration:09/20/1990
EDUCATIONAL BACKGROUND (Most Recent)
Period of Attendance Highest Level/
Year
Level Name of School Degree/ Course Units Earned if
Graduated
From To not graduated
Graduate Studies
Tertiary BUTUAN DOCTORS’
BACHELOR OF 2007 2011 2011
COLLEGE SCIENCE IN
NURSING
PRESENT WORK EXPERIENCE/ HEALTH FACILITY INFORMATION
Position Title Name of Facility Type of Facility
☐Rural Health Unit ☐Private Medical Clinics
NDP-NURSE II DOH-CHD CARAGA ☐Municipal/City/Provincial Health Office
☐Birthing Home ☐Hospital/Infirmary
Status of Employment Type of Ownership ☐Barangay Health Station
☐Others, pls. specify: ___________
☐Private-owned ☐Government-owned
CONTRACTUAL PhilHealth eKonsulta Accredited
☐Yes ☐No
Complete Address of the Health Facility Region: CARAGA
(Floor, Building Name, No., Street, Barangay, Municipal/City, Province, Postal Code)
Province:AGUSAN DEL NORTE
P4 STO. NINO, BUTUAN CITY Municipality/ City: BUTUAN CITY
CURRENT ROLES AND RESPONSIBILITIES (Use separate paper, if necessary)
Conducts regular visits to priority households with health problems ,Prepares health status reports of
families/households visited, Plans for appropriate interventions on the identified health concerns of
families/households, Assist in the preparation of barangay health plans, Supervise, train, orient the BHWs
and conduct regular monitoring and evaluation of various health programs together with the MHO, PHN,
and DMO, Participates in the implementation of health programs of DOH and the LGU in the community,
Conducts health education, advocacies and training on different DOH programs, Participates in data
gathering and response during health emergencies and disasters and, Performs other related functions as
may be assigned subject to the approval of the DOH

I hereby declare that all of the submitted documents and information provided with this application form are
true, correct, and complete pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of the
Philippines.

I authorized the agency head/ authorized representative to verify/ validate the content stated herein.

CHRISTINE ANNE M. REMITAR, RN 11/06/2023

Applicant’s Signature Over Printed Name Date

DOH-PCP-Applicants Information Sheet (Form 1)

Revision 2
December 2022