Republic of the Philippines

DEPARTMENT OF HEALTH

PRIMARY CARE WORKERS’ CERTIFICATION PROGRAM

APPLICANT’S INFORMATION SHEET
APPLICANT’S PERSONAL INFORMATION
Name (Last Name, First Name, Middle Name) Suffix/ Extension Name Sex
☐Male
LOQUIAS, SHEILA MAE SIBI xFemale
Date of Birth (mm/dd/yyyy) Age Citizenship Civil Status
x Filipino ☐Single ☐Widowed
February 12, 1987 35 ☐Dual Citizenship; x Married ☐ Separated
Country:_________ ☐Others: ____________
Active Mobile Number Active Email Address
09562712005 Office Email: Personal Email: sibis2504@gmail.com
Profession PRC License
NURSE Number: 0688574 Date of Issuance: 03/11/2011 Date of Expiration:02/12/2023

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 The College of Bachelor of Science in 2005 2009 2009
Maasin Nursing
Tertiary
PRESENT WORK EXPERIENCE/ HEALTH FACILITY INFORMATION
Position Title Name of Facility Type of Facility
NURSE II MAASIN CITY HEALTH UNIT I ☐Rural Health Unit ☐Private Medical Clinics
X City/Municipal Health Office
Status of Employment Type of Ownership ☐Others, pls. specify: _______________
PS CONTRACTUAL
☐Private-owned X Government-owned
Complete Address of the Health Facility Region: REGION VIII
(Floor, Building Name, No., Street, Barangay, Municipal/City, Province, Postal Code)
Province: SOUTHERN LEYTE
PROVINCIAL DOH, DONGON MAASIN CITY SOUTHERN LEYTE Municipality/ City: MAASIN CITY

CURRENT ROLES AND RESPONSIBILITIES (Use separate paper, if necessary)

1.Conducts regular visit to priority households

2. Assists in the conduct of disease surveillance
3. Assist in the implementation of various health programs of the LGU
4. Assists in the preparation of reports on the clinic and community activities
5. Conducts health education

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.

DOH-PCP-Applicants Information Sheet (Form 1)

Revision 1
January 2022
 Sheila Mae S. Loquias 07/28/2022
Applicant’s Signature Over Printed Name Date

- - - - - - - - Please do not print this page - - - - - - - - -

Instructions: Please be informed that we are only providing “Viewer” access for this file. To edit the
PCW Applicant’s Information Sheet, click the “File” button on the top left, click the “Download” and
click “Microsoft Word (.docx)”. Provide your complete information on the downloaded template and
submit it to this online form: bit.ly/ProvisionalCPC_Application.

Thank you.

DOH-PCP-Applicants Information Sheet (Form 1)

Revision 1
January 2022