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 (Do not fill up. For CSC use only)
I. PERSONAL INFORMATION
2. SURNAME CIMAGALA
NAME EXTENSION (JR., SR) N/A
FIRST NAME MELODY
MIDDLE NAME MATA
3. DATE OF BIRTH
(mm/dd/yyyy) 07/14/1986 16. CITIZENSHIP FILIPINO

4. PLACE OF BIRTH DAVAO CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX FEMALE

6 CIVIL STATUS SINGLE

17. RESIDENTIAL ADDRESS N/A LANZONA VILLAGE
House/Block/Lot No. Street
PUROK 17 CALINAN
Subdivision/Village Barangay

7. HEIGHT (m) 1.55 m DAVAO DAVAO DEL-SUR

City/Municipality Province
8. WEIGHT (kg) 46 kg ZIP CODE 8000

9. BLOOD TYPE A+
18. PERMANENT ADDRESS N/A LANZONA VILLAGE
House/Block/Lot No. Street

10. GSIS ID NO. N/A PUROK 17 CALINAN

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 121200353435 DAVAO DAVAO DEL-SUR

City/Municipality Province

12. PHILHEALTH NO. 160253097490 ZIP CODE 8000

13. SSS NO. 0934398480 19. TELEPHONE NO. N/A

14. TIN NO. 45257141800 20. MOBILE NO. 0912-257-2274

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) mimicimagala14@[Link]
II. FAMILY BACKGROUND
DATE OF BIRTH
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) (mm/dd/yyyy)
NAME EXTENSION (JR., SR)
FIRST NAME N/A N/A SAMANTHA NICHOLE CIMAGALA 10/18/2006

MIDDLE NAME N/A NOTHING FOLLOWS NOTHING FOLLOWS

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME CIMAGALA

NAME EXTENSION (JR., SR)
FIRST NAME EPITACIO JR

MIDDLE NAME INDOLOS

25. MOTHER'S MAIDEN NAME VILLARTA

SURNAME CIMAGALA

FIRST NAME EDITHA

MIDDLE NAME MATA (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY
HOLY CROSS COLLEGE OF ELEMENTARY 1993 1999 GRADUATED 1999 N/A
CALINAN

SECONDARY /
HOLY CROSS COLLEGE OF HIGH SCHOOL 1999 2003 GRADUATED 2003 N/A
VOCATIONAL CALINAN

N/A N/A N/A N/A N/A N/A N/A

TRADE COURSE MINDANAO MEDICAL BACHELOR OF SCIENCE IN

COLLEGE
FOUNDATION COLLEGE NURSING 2007 2009 GRADUATED 2009 N/A

GRADUATE STUDIES N/A N/A N/A N/A N/A N/A N/A

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/15/2023

CS FORM 212 (Revised 2017), Page 1 of 4
IV. CIVIL SERVICE ELIGIBILITY
27. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER SPECIAL LAWS/ RATING DATE OF
CES/ CSEE BARANGAY ELIGIBILITY / (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

RA 1080 (REGISTERED NURSE) 75.00% MAY 30 2015 - DAVAO CITY 0866113 7/14/2024
MAY 31 2015

NOTHING FOLLOWS NOTHING FOLLOWS NOTHING NOTHING FOLLOWS NOTHING NOTHING

FOLLOWS FOLLOWS FOLLOWS

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

01/1/2023 PRESENT NURSE DEPLOYMENT PROGRAM (NURSE II) DEPARTMENT OF HEALTH 39,762.00 SG 16/1 CONTRACT OF
SERVICE
Y
03/2/2022 12/31/2022 NURSE DEPLOYMENT PROGRAM (NURSE II) DEPARTMENT OF HEALTH 38,150.00 SG 16/1 CONTRACT OF
SERVICE Y
01/10/2022 2/28/2022 NURSE I DEPARTMENT OF HEALTH 33,575.00 SG 15/1 CONTRACT OF Y
SERVICE

2/8/2021 12/31/2021 NURSE DEPLOYMENT PROGRAM (NURSE I) DEPARTMENT OF HEALTH 33,575.00 SG 15/1 PS
CONTRACTUAL Y

8/9/2015 07/31/2021 REGISTERED NURSE CLINICA ISAGUIRRE 13,000.00 N/A REGULAR N

10/1/2014 05/14/2015 CALL CENTER AGENT SUTHERLAND GLOBAL SERVICE 12,000.00 N/A CONTRACTUAL N

1/10/2012 12/14/2013 ENUMERATOR/ TEAM SUPERVISOR NATIONAL STATISTICS OFFICE 10,000.00 N/A PROJECT BASE Y

NOTHING NOTHING NOTHING FOLLOWS NOTHING FOLLOWS NOTHING NOTHING NOTHING NOTHING
FOLLOWS FOLLOWS FOLLOWS FOLLOWS FOLLOWS FOLLOWS

(Continue on separate sheet if necessary)

SIGNATURE DATE 12/15/2023

CS FORM 212 (Revised 2017), Page 2 of 4
VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT / PEOPLE / VOLUNTARY ORGANIZATION/S

29. NAME & ADDRESS OF ORGANIZATION INCLUSIVE DATES

(mm/dd/yyyy) NUMBER OF
POSITION / NATURE OF WORK
(Write in full) HOURS
From To

N/A N/A N/A N/A 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)

30. INCLUSIVE DATES OF ATTENDANCE Type of LD

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

FOCUSED ANTENATAL CARE 10/20/2022 10/20/2022 8 HOURS TECHNICAL DEPARTMENT OF HEALTH

ADOLESCENT HEALTH EDUCATION AND PRACTICAL TRAINING 7/15/2022 7/15/2022 8 HOURS TECHNICAL DEPARTMENT OF HEALTH

DENGUE LECTURE SERIES 5/19/2022 5/19/2022 3 HOURS TECHNICAL SOUTHERN PHILIPPINES MEDICAL CENTE

ORIENTATION ON THE UNIVERSAL HEALTH CARE LAW 12/09/2021 12/09/2021 3 HOURS TECHNICAL DEPARTMENT OF HEALTH

DOH PRIMARY CARE WORKER'S ONLINE ORIENTATIOM 12/04/2021 12/04/2021 3 HOURS TECHNICAL DEPARTMENT OF HEALTH

ADVANCED AIRWAY MANAGEMENT 10/19/2020 10/19/2020 3 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

BASIC CARDIAC RHYTHM 10/19/2020 10/19/2020 3 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

RECOGNITION COVID 19 10/19/2020 10/19/2020 2 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

RESCUSITATION GUIDELINES 10/20/2020 10/20/2020 2 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

ELECTRICAL THERAPY AND MED 10/20/2020 10/20/2020 2 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

OPERATION EMERGENCY 10/20/2020 10/20/2020 2 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

CARDIOVASCULAR MEDICATIONS 10/20/2020 10/20/2020 2 HOURS TECHNICAL LINE HEART LEARNING AND
DEVELOPMENT

NOTHING FOLLOWS NOTHING FOLLOWS NOTHING FOLLOWS NOTHING NOTHING

FOLLOWS FOLLOWS NOTHING FOLLOWS

(Continue on separate sheet if necessary)

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

CLEANING N/A N/A

FAMILY TIME

LISTENING TO MUSIC

GARDENING

SINGING

WATCHING TV
(Continue on separate sheet if necessary)

SIGNATURE DATE 12/15/2023

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 theof bureau or office or to the person who has immediate supervision over you in the
chief
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 out (abolition) in the public or private sector? If YES, give details:
________________________________
________________________________
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
LAREDO P. RABANG, MD TUGBOK DAVAO CITY 09177569351 3.5 cm. X 4.5 cm
(passport size)

EVANGELINE M. DAYRIT, RN TUGBOK DAVAO CITY 09161909836 With full and handwritten
name tag and signature over
printed name
CAPT. REY AMADOR M. BARGAMENTO MINTAL DAVAO CITY 09422571068
Computer generated
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.
or photocopied picture
is not acceptable

PHOTO

Government Issued ID ([Link], GSIS, SSS, PRC, Driver's License,

etc.) PLEASE INDICATE ID Number and
Date of Issuance
Government Issued ID: PRC LICENSE
Signature (Sign inside the box)
ID/License/Passport No.: 0866113
12/15/2023
Right Thumbmark
Date/Place of Issuance: 07/23/2015/ DAVAO CITY

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