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 YU
NAME EXTENSION (JR., SR)
FIRST NAME GLADYS
MIDDLE NAME CINCO
3. DATE OF BIRTH
(mm/dd/yyyy) 09/13/1989 16. CITIZENSHIP ✘ Filipino Dual Citizenship
by
by naturalization
birth
4. PLACE OF BIRTH COTABATO CITY If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female
✘ Single Married 17. RESIDENTIAL ADDRESS BORMAHECO DRIVE SINSUAT AVENUE
6 CIVIL STATUS
Widowed Separated House/Block/Lot No. Street
Other/s: ROSARY HEIGHTS IV
Subdivision/Village Barangay
COTABATO CITY
7. HEIGHT (m) 1.52
City/Municipality Province
8. WEIGHT (kg) 68 ZIP CODE 9600
18. PERMANENT ADDRESS BORMAHECO DRIVE SINSUAT AVENUE
9. BLOOD TYPE O+
House/Block/Lot No. Street
ROSARY HEIGHTS IV
10. GSIS ID NO. 2005612753
Subdivision/Village Barangay
COTABATO CITY
11. PAG-IBIG ID NO. 1211 6439 3683
City/Municipality Province
12. PHILHEALTH NO. 17-025277252-1 ZIP CODE 9600
13. SSS NO. 0934407782 19. TELEPHONE NO. (064) 557-2490
14. TIN NO. 455-652-435 20. MOBILE NO. +639053531306
15. AGENCY EMPLOYEE NO. 619 21. E-MAIL ADDRESS (if any) gladyscyu@yahoo.com
II. FAMILY BACKGROUND
22. SPOUSE'S SURNAME N/A 23. NAME of CHILDREN (Write full name and list all) DATE OF BIRTH (mm/dd/yyyy)
NAME EXTENSION (JR., SR) AL-REGGIE YU KANAKAN
FIRST NAME 08/30/2009
MIDDLE NAME YUAN KAE YU CARLOS 10/12/2019
OCCUPATION AUSTIN KAE YU CARLOS 11/18/2021
EMPLOYER/BUSINESS NAME
BUSINESS ADDRESS
TELEPHONE NO.
24. FATHER'S SURNAME YU
NAME EXTENSION (JR., SR)
FIRST NAME RAMON
MIDDLE NAME SARION
25. MOTHER'S MAIDEN NAME
SURNAME CINCO
FIRST NAME GRACE
MIDDLE NAME TILLO (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
ELEMENTARY Cotabato City Central Pilot School 1996 2002
SECONDARY /
VOCATIONAL Notre Dame Village National High School 2002 2006
TRADE
COURSE
COLLEGE Notre Dame University 2006 2011
GRADUATE STUDIES
(Continue on separate sheet if necessary)
SIGNATURE DATE December 9, 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
Philippine Nursing Licensure Examination 79% 1/7/2011 0721837 09/29/2011
(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)
3/1/2019 present Nurse I Cotabato Regional and Medical Center P33,575 PERMANENT Y
05/18/2015 2/1/2019 Job Order Nurse Cotabato Regional and Medical Center P7,810 CONTRACTUAL Y
01/22/2014 05/17/2015 Nurse Deployment Project (NDP) South Upi Municipal Hospital P18,549 CONTRACTUAL Y
4/9/2013 12/31/2014 RN Heals South Upi Municipal Hospital P8,000 CONTRACTUAL Y
4/3/2013 3/9/2014 RN Heals Datu Blah T. Sinsuat District Hospital P8,000 CONTRACTUAL Y
4/11/2011 12/31/2012 RN Heals Cotabato Regional and Medical Center P8,900 CONTRACTUAL Y
(Continue on separate sheet if necessary)
SIGNATURE DATE December 9, 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
None
(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
ATTENDANCE Type of LD
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ( Managerial/ CONDUCTED/ SPONSORED BY
NUMBER OF HOURS
(Write in full) Supervisory/ (Write in full)
(mm/dd/yyyy)
Technical/etc)
From To
LEARNING AND DEVELOPMENT PLAN SEMINAR 01/22/2019 01/22/2019 8 HOURS TECHNICAL COTABATO REGIONAL AND MEDICAL CENTER
BLEEDING CONTROL BASIC V. 1.0 COURSE 3/7/2018 3/7/2018 3 HOURS TECHNICAL ATTY. JOEL U MACALINO, MD, FPCS, FACS
DATA PRIVACY ACT ORIENTATION 01/18/2018 01/18/2018 5 HOURS TECHNICAL COTABATO REGIONAL AND MEDICAL CENTER
NGITI PARA SA KAPAYAPAAN-OPERATION BUNGI (CRMC) 3/1/2018 6/1/2018 32 HOURS TECHNICAL SMILE TRAIN INTERNATIONAL FOUNDATION
PHA-TSEKAP SURGIVAL CARAVAN (CRMC) 11/12/2017 12/16/2017 48 HOURS TECHNICAL DEPARTMENT OF HEALTH REGION NO. 12
2017 DOH SURGICAL CARAVAN (SOUTH COTABATO PROVINCIAL HOSPITAL) 11/25/2017 1/12/2017 56 HOURS TECHNICAL DEPARTMENT OF HEALTH REGION NO. 12
2017 DOH SURGICAL CARAVAN (DR. CORNELIO M. MARTINEZ, SR. MEMORIAL HOSPITAL) 10/23/2017 10/27/2017 40 HOURS TECHNICAL DEPARTMENT OF HEALTH REGION NO. 12
ISO 9001:2015 AWARENESS SEMINAR 07/17/2017 07/17/2017 4 HOURS TECHNICAL COTABATO REGIONAL AND MEDICAL CENTER
BIOSAFETY SEMINAR WORKSHOP FOR BLOOD SERVICE FACILITY PERSONNEL 04/25/2016 04/25/2016 4 HOURS TECHNICAL COTABATO REGIONAL AND MEDICAL CENTER
NATIONWIDE MASS TRAINING ON CARDIOPULMONARY RESUSCITATION 04/25/2016 04/25/2016 4 HOURS TECHNICAL COTABATO REGIONAL AND MEDICAL CENTER
ENHANCEMENT TRAINING FOR NEW STAFF NURSES 9/2/2016 02/23/2016 80 HOURS TECHNICAL COTABATO REGIONAL AND 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)
COMPUTER AND INTERNET LITERATE NONE PHILIPPINE NURSES ASSOCIATION
ASSOCIATION OF NURSING SERVICE
ADMINISTRATORS OF THE PHILIPPINES
(Continue on separate sheet if necessary)
SIGNATURE DATE December 9, 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 ✘
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘
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
YES ✘ NO
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, YES ✘ NO
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
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
the last 6 months
Ester S. Petilo, MD, FPOGS South Upi Municipal Hospital 9053525675 3.5 cm. X 4.5 cm
(passport size)
Rosalie O. Luces, MAN, RN Cotabato Regional and Medical Center 9129099656 With full and handwritten
name tag and signature over
printed name
Parida K. Satol, MAN, RN, CHA Cotabato Regional and Medical Center 9174470268
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
is not acceptable
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 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: 619
ID/License/Passport No.: 0721837 Signature (Sign inside the box)
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
