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 QUETUA
NAME EXTENSION (JR., SR) NA
FIRST NAME LOVELY VANESSA

MIDDLE NAME JACOB

3. DATE OF BIRTH
(mm/dd/yyyy) 08/17/1986 16. CITIZENSHIP

4. PLACE OF BIRTH MANILA If holder of dual citizenship, Pls. indicate country:

please indicate the details.
5. SEX

6 CIVIL STATUS
17. RESIDENTIAL ADDRESS 12 DELOS REYES ST.
House/Block/Lot No. Street
BAHAY TORO
Subdivision/Village Barangay
7. HEIGHT (m) 1.57 QUEZON CITY
City/Municipality Province
8. WEIGHT (kg) 48 ZIP CODE 1101

9. BLOOD TYPE O+
18. PERMANENT ADDRESS 28 ANGELES EXTENSION
House/Block/Lot No. Street

10. GSIS ID NO. 0111-2884422-8 KRUS NA LIGAS

Subdivision/Village Barangay
QUEZON CITY NCR
11. PAG-IBIG ID NO. 121003647696
City/Municipality Province

12. PHILHEALTH NO. 03-025081746-7 ZIP CODE 1101

13. SSS NO. 34-1637235-8 19. TELEPHONE NO. N/A

14. TIN NO. 310-241-111 20. MOBILE NO. 09152211248

15. AGENCY EMPLOYEE NO. CT-0030689 21. E-MAIL ADDRESS (if any) lovelyquetua@gmail.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)

FIRST NAME
NAME EXTENSION (JR., SR)
N/A
MIDDLE NAME

OCCUPATION

EMPLOYER/BUSINESS NAME

BUSINESS ADDRESS

TELEPHONE NO.

24. FATHER'S SURNAME QUETUA

NAME EXTENSION (JR., SR)
FIRST NAME MARIO

MIDDLE NAME SALVADOR

25. MOTHER'S MAIDEN NAME

SURNAME JACOB

FIRST NAME MELVIN

MIDDLE NAME DELA CRUZ (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 PURA V. KALAW PRIMARY 06/03/1996 03/10/2000 GRADUATED 2000 N/A

SECONDARY RAMON MAGSAYSAY (CUBAO) HIGH SCHOOL 06/04/2001 03/12/2004 GRADUATED 2004 N/A
VOCATIONAL /

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

TRADE
SYDP- c/o
COURSE
COLLEGE OUR LADY OF FATIMA UNIVERSITY BACHELOR OF SCIENCE IN NURSING 06/07/2004 03/10/2008 GRADUATED 2008
QC

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

(Continue on separate sheet if necessary)

SIGNATURE DATE
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
11/29/2008 -
PHILIPPINE NURSE LICENSURE EXAMINATION 78.2 11/30/2008
MANILA 0530711 08/17/2021

(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
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT
From To
(Y/ N)
CONTRACT OF
01/01/2021 PRESENT NURSE QUEZON CITY HEALTH DEPARTMENT 32,053.00 15 SERVICE Y
OFFICE OF THE CITY MAYOR, QUEZON CONTRACT OF
07/27/2020 12/31/2020 DISEASE SURVEILLANCE OFFICER 32,053.00 15 Y
CITY SERVICE

04/17/2018 05/22/2020 STAFF NURSE DILIMAN DOCTORS HOSPITAL 17,000.00 8 REGULAR N

10/09/2016 04/20/2017 ORDER SUPPORT REPRESENTATIIVE AFNI PHILIPPINES 23,000.00 11 REGULAR N

02/08/2016 06/30/2016 NURSE ASSOCIATE COGNIZANT SOLUTIONS 27,000.00 13 PROBATIONARY N

05/12/2014 01/12/2016 CUSTOMER SERVICE ASSOCIATE MANULIFE PHILIPPINES 18,000.00 9 REGULAR N

09/08/2011 05/05 /014 CUSTOMER SERVICE REPRESENTATIVE SITEL PHILIPPINES 15,000.00 6 REGULAR N
ATENEO DE MANILA HIGH SCHOOL CONTRACT OF
04/20/2010 06/18/2010 SECRETARY 10,000.00 1 N
DIVISION SERVICE
ARMED FORCES OF THE PHILIPPINES
08/10/2009 03/02/2010 RESIDENT NURSE - 0 VOLUNTEER Y
MEDICAL CENTER

(Continue on separate sheet if necessary)

SIGNATURE DATE
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

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)
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

ORIENTATION ON THE UNIVERSAL HEALTH CARE LAW 8/8/2022 8/8/2022 2.0 N/A DOH ACADEMY ONLINE COURSE

DOH PRIMARY CARE WORKER'S ONLINE ORIENTATION 8/8/2022 8/8/2022 4.0 N/A DOH ACADEMY ONLINE COURSE

ONLINE TRAINING ON BASIC EPIDEMIOLOGY 6/23/2022 6/23/2022 8.6 N/A DOH ACADEMY ONLINE COURSE

COURSERA ; COVID-19 CONTACT TRACING 07/27/2020 07/27/2020 6.0 N/A ONLINE COURSE BY JOHN HOPKINS

BASIC LIFE SUPPORT -AMERICAN HEART ASSOCIATION 10/12/2019 10/12/2019 4.0 N/A DILIMAN DOCTORS HOSPITAL

NURSING SKILSS ENHANCEMENT PROGRAM 09/06/2019 09/06/2019 8.0 N/A DILIMAN DOCTORS HOSPITAL

DELIVERING DESIRABLE HEALTHCARE IN PEDIATRICS 08/26/2019 08/26/2019 8.0 N/A DILIMAN DOCTORS HOSPITAL

LANGUAGE OF CARE 07/13/2019 07/13/2019 4.0 N/A DILIMAN DOCTORS HOSPITAL

ASSOCIATION OF NURSING SERVICE
REGULAR INTRAVENOUS THERAPHY TRAINING PROGRAM 05/22/2018 05/24/2018 24.0 N/A ADMINISTRATORS OF THE PHILIPPINES
(ANSAP)
PHILIPPINE NATIONAL RED CROSS-
STANDARD FIRST-AID AND BLS-CARDIOPULMONARY RESUSCITATION WITH AED 04/09/2018 04/13/2018 40.0 N/A
QUEZON CITY CHAPTER

(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)

BASIC NURSING SKILLS N/A N/A

INTRAVENOUS THERAPHY NURSE

COMPUTER LITERATE

INTERPERSONAL SKILLS

DANCING AND PLAYING GUITAR

(Continue on separate sheet if necessary)

SIGNATURE DATE
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? FINISHED CONTRACT
________________________________
________________________________
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
TELEDIRECT PHILIPPINES AT SHERIDAN the last 6 months
KIZZY A. RAPINAN ST. MANDALUYONG PASIG CITY
9395243911 3.5 cm. X 4.5 cm
(passport size)
QUEZON CITY EPIDEMIOLOGY AND
DIANE MANSALAY SURVEILLANCE UNIT
9062712117 With full and handwritten
name tag and signature over
MANULIFE PHILIPPINES- U.P. printed name
CARLINE AGUSTIN TECHNOHUB COMMONWEALTH Q.C.
9338189896
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: PRC

ID/License/Passport No.: 0530711 Signature (Sign inside the box)

Date/Place of Issuance: MANILA

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