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 Desabelle
NAME EXTENSION (JR., SR)
FIRST NAME Carol
MIDDLE NAME Ephan
3. DATE OF BIRTH
(mm/dd/yyyy) 05-10-1967 16. CITIZENSHIP Filipino

4. PLACE OF BIRTH Bansalan, Davao del Sur If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Female
6 CIVIL STATUS Widowed 17. RESIDENTIAL ADDRESS 1735 Lopez Jaena Extension
House/Block/Lot No. Street
Zone 1
Subdivision/Village Barangay
7. HEIGHT (m) 1.58496 Digos City Davao del Sur
City/Municipality Province
8. WEIGHT (kg) 59 kgs ZIP CODE 8002
9. BLOOD TYPE B+ 18. PERMANENT ADDRESS 1735 Lopez Jaena Extension
House/Block/Lot No. Street
10. GSIS ID NO. CM-3364361 Zone 1
Subdivision/Village Barangay

11. PAG-IBIG ID NO. 1880-0131-3085 Digos City Davao del Sur

City/Municipality Province

12. PHILHEALTH NO. 16-000014513-8 ZIP CODE 8002

13. SSS NO. NONE 19. TELEPHONE NO. None
14. TIN NO. 142-570-680 20. MOBILE NO. 0930-534-5343
15. AGENCY EMPLOYEE NO. 401 21. E-MAIL ADDRESS (if any) caroldesabelle0567@gmail.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME Desabelle 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)

FIRST NAME Roberto (Deceased)

NAME EXTENSION (JR., SR)
Robert Carlo E. Desabelle July 02, 1990
MIDDLE NAME Pastor Robee Camille E. Desabelle June 12, 1991
OCCUPATION None Rae Kristine E. Desabelle October 28, 1992
EMPLOYER/BUSINESS NAME None Renz Christian E. Desabelle August 20, 1996
BUSINESS ADDRESS None
TELEPHONE NO. None
24. FATHER'S SURNAME Ephan
NAME EXTENSION (JR., SR)
FIRST NAME Gonzalo SR.

MIDDLE NAME Dumagan

25. MOTHER'S MAIDEN NAME

SURNAME Valenzona
FIRST NAME Resurrecion
MIDDLE NAME Suarez (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
Bansalan Central Elementary 3rd
ELEMENTARY Elementary 1975 1980 Graduate 1980 Honorable
School
Holy Cross College of With
SECONDARY /
VOCATIONAL Secondary 1980 1984 Graduate 1984
Bansalan Honors
N/A N/A N/A N/A N/A N/A N/A
TRADE
Bachelor of Science in
COURSE
COLLEGE Brokenshire College 1984 1988 Graduate 1988 None
Nursing
GRADUATE STUDIES Davao Doctors College Master of Arts in Nursing 2012 2014 Graduate 2014 None
(Continue on separate sheet if necessary)

SIGNATURE DATE July 02, 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
(If Applicable) NUMBER Date of
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT
Validity
June 6-7,
Nurse Licensure Examination 80.27% Manila, Philippines 0161477 May 10, 2024
1988

(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
(Format "00-0")/
abbreviate) full/Do not abbreviate) INCREMENT
From To
(Y/ N)

01-01-2021 Present Nurse II Provincial Health Office 35513.00 15-6 Permanent Y

09-01-2020 12-31-2020 Nurse II Provincial Health Office 33994.00 15-6 Permanent Y

01-01-2020 08-31-2020 Nurse II Provincial Health Office 33594.00 15-6 Permanent Y

01-01-2019 12-31-2019 Nurse II Provincial Health Office 32072.00 15-5 Permanent Y

01-01-2018 12-31-2018 Nurse II Provincial Health Office 30432.00 15-5 Permanent Y

09-01-2017 12-31-2017 Nurse II Provincial Health Office 28877.00 15-5 Permanent Y

01-01-2017 08-31-2017 Nurse II Provincial Health Office 28544.00 15-4 Permanent Y

01-01-2016 12-31-2016 Nurse II Provincial Health Office 27094.00 15-4 Permanent Y

09-01-2014 12-31-2015 Nurse II Provincial Health Office 25718.00 15-4 Permanent Y

01-01-2013 08-31-2014 Nurse II Provincial Health Office 25438.00 15-3 Permanent Y

01-01-2012 12-31-2012 Nurse II Provincial Health Office 23305.00 15-3 Permanent Y

09-01-2011 12-31-2011 Nurse II Provincial Health Office 21172.00 15-3 Permanent Y

01-01-2011 08-31-2011 Nurse II Provincial Health Office 20827.00 15-2 Permanent Y

01-01-2010 12-31-2010 Nurse II Provincial Health Office 18661.00 15-2 Permanent Y

09-01-2008 12-31-2009 Nurse II Provincial Health Office 15562.00 15-2 Permanent Y

07-01-2008 08-31-2008 Nurse II Provincial Health Office 15181.00 15-1 Permanent Y

07-01-2007 06-30-2008 Nurse II Provincial Health Office 13801.00 15-1 Permanent Y

09-01-2005 06-30-2007 Nurse II Provincial Health Office 12546.00 15-1 Permanent Y

06-05-2002 08-31-2005 Nurse I Provincial Health Office 10971.00 15-1 Permanent Y

07-01-2001 06-04-2002 Nurse I Provincial Health Office 10704.00 15-1 Permanent Y

01-01-2000 06-30-2001 Nurse I Provincial Health Office 10194.00 15-1 Permanent Y

06-05-1999 12-31-1999 Nurse I Provincial Health Office 9350.33 15-1 Permanent Y

11-01-1997 06-04-1999 Nurse I Provincial Health Office 9041.00 15-1 Permanent Y

01-01-1997 10-31-1997 Nurse I Provincial Health Office 7558.00 15-1 Permanent Y

06-05-1996 12-31-1996 Nurse I Provincial Health Office 6075.00 15-1 Permanent Y

01-01-1996 06-04-1996 Nurse I Provincial Health Office 6044.00 15-1 Permanent Y

01-01-1995 12-31-1995 Nurse I Provincial Health Office 4933.00 15-1 Permanent Y

01-01-1994 12-31-1994 Nurse I Provincial Health Office 3933.00 15-1 Permanent Y

(Continue on separate sheet if necessary)

SIGNATURE DATE July 02, 2021

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

Provincial Government Emplyoees Association

(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

Training on Hospital Infection Control for Doctors and Nurses 11-18-2015 11-20-2015 24hours Technical Department of Health Region XI

Annual Evaluation of Info System 09-02-2015 09-03-2015 16hours Technical Department of Health Region XI

Orientation on Middle East Respiratory Syndrome Coronavirus 06-29-2015 06-30-2015 16hours Technical Department of Health Region XI
Translating Scientific Evidence to Pratical Strategies in the Practical of Philippine Hospital Infection Control
Infection Prevention and Control
05-28-2015 8hours Technical Society
Orientation on Ovi-Larvae Trap for Infection Control Nurses 05-07-2015 05-07-2015 8hours Technical Department of Health Region XI

Training on Donning and Doffing of PPE in Ebola Virus Disease 12-16-2014 12-16-2014 8hours Technical Department of Health Region XI

Pathologic Colors in Children 12-04-2014 12-04-2014 8hours Technical Wyeth

Orientation on Emerging and Re-Emerging of Infectious Disease 11-18-2014 11-19-2014 16hours Technical Department of Health Region XI

Neurosurgical Case and Monitoring Training 10-21-2014 10-21-2014 8 hours Technical Southern Philippines Medical Center

(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)

Singing N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE July 02, 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?
b. within the fourth degree (for Local Government Unit - Career Employees)?
If YES, give details:
________________________________
________________________________
35. a. Have you ever been found guilty of any administrative offense?
If YES, give details:
________________________________
________________________________
b. Have you been criminally charged before any court?
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?
If YES, give details:
________________________________
________________________________
37. Have you ever been separated from the service in any of the following modes: resignation,
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)?
If YES, give details:
b. Have you resigned from the government service during the three (3)-month period before the last
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?
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?
If YES, please specify:
b. Are you a person with disability?
If YES, please specify ID No:
c. Are you a solo parent?
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. Jaime Marcelo M. Razo Digos City 9995988887 4.5 cm. X 3.5 cm
(passport size)

Dr. Elpidio R. Monarca Digos City 9205149079

Computer generated
or photocopied picture
Mrs. Lorna N. Capuyan, RN Digos City 9208184456 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 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: PRC
ID/License/Passport No.: 0161477 Signature (Sign inside the box)
07-02-2021
Date/Place of Issuance: Manila / 04-24-1989 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