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

MIDDLE NAME RAPADA

3. DATE OF BIRTH
09/15/1989 16. CITIZENSHIP
(mm/dd/yyyy) ✘ Filipino Dual Citizenship
by by
birth naturalization
4. PLACE OF BIRTH GENERAL MACARTHUR, EAST. SAMAR If holder of dual citizenship, Pls. indicate country:
please indicate the details.
5. SEX Male ✘ Female

6 CIVIL STATUS ✘ Single Married 17. RESIDENTIAL ADDRESS 5A FONTAINE EXTENSION

House/Block/Lot No. Street
Separat
Widowed N/A EAST TAPINAC
Other/s: ed
Subdivision/Village Barangay

7. HEIGHT (m) 1.57 OLONGAPO CITY ZAMBALES

City/Municipality Province
8. WEIGHT (kg) 83 ZIP CODE 2200

9. BLOOD TYPE O+ 18. PERMANENT ADDRESS 5A FONTAINE EXTENSION

House/Block/Lot No. Street

10. GSIS ID NO. N/A N/A EAST TAPINAC

Subdivision/Village Barangay

11. PAG-IBIG ID NO. 0121128675996 OLONGAPO CITY ZAMBALES

City/Municipality Province

12. PHILHEALTH NO. 070256447558 ZIP CODE 2200

13. SSS NO. 0237364250 19. TELEPHONE NO. N/A

14. TIN NO. 459106564000 20. MOBILE NO. 0926-755-2134

15. AGENCY EMPLOYEE NO. N/A 21. E-MAIL ADDRESS (if any) [email protected]

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) N/A
FIRST NAME N/A N/A N/A

MIDDLE NAME N/A

OCCUPATION N/A

EMPLOYER/BUSINESS NAME N/A

BUSINESS ADDRESS N/A

TELEPHONE NO. N/A

24. FATHER'S SURNAME BAULA

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

MIDDLE NAME CORRE

25. MOTHER'S MAIDEN NAME

SURNAME RAPADA

FIRST NAME CARMILITA

MIDDLE NAME GAHOY (Continue on separate sheet if necessary)

III. EDUCATIONAL BACKGROUND

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

ELEMENTARY
GENERAL MACARTHUR CENTRAL ELEMENTARY GRADUATE 1997 2003 N/A 2003 N/A
ELEMENTARY SCHOOL

SECONDARY TALA HIGH SCHOOL HIGH SCHOOL GRADUATE 2003 2007 N/A 2007 N/A
VOCATIONAL /

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

TRADE
COURSE
COLLEGE GORDON COLLEGE GRADUATE IN MIDWIFERY/ 2007 2013 N/A 2009/2013 N/A
BACHELOR SCIENCE IN NURSING

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. LICENSE (if applicable)
CAREER SERVICE/ RA 1080 (BOARD/ BAR) UNDER RATING DATE OF
SPECIAL LAWS/ CES/ CSEE (If Applicable) EXAMINATION / PLACE OF EXAMINATION / CONFERMENT
BARANGAY ELIGIBILITY / DRIVER'S LICENSE CONFERMENT NUMBER Date of
Validity

RA 1080 (MIDWIFE) 79.3 04/28-29/2009 QUEZON CITY, METRO MANILA, PHILIPPINES 0148485 09/15/2026

PHILIPPINE NURSING LICENSURE EXAMINATION 76.4 12/07-08/2013 QUEZON CITY, METRO MANILA, PHILIPPINES 0843016 09/15/2026

DRIVER'S LICENSE N/A 2/8/2022 OLONGAPO CITY, ZAMBALES, PHILIPPINES C09-22-002202 09/15/2026

(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
(Write in full/Do not (Write in SALARY
applicable)& STEP
APPOINTMENT
abbreviate) full/Do not abbreviate) (Format "00-0")/
INCREMENT (Y/
From To N)

04/16/2024 12/31/2024 NURSE VACCINATOR DEPARTMENT OF HEALTH 36619.00 15-1 CONTRACTUAL Y

1/2/2021 02/20/2024 STAFF NURSE TRIBOA MEDTECH INC. 12482.00 N/A PERMANENT N

01/15/2019 01/15/2021 PRIVATE DUTY NURSE N/A 11500.00 N/A CONTRACTUAL N

11/20/2015 10/30/2018 PRIVATE CAREGIVER/ TUTOR N/A 11000.00 N/A CONTRACTUAL N

1/3/2015 08/30/2015 STAFF NURSE BIOLINE DIAGNOSTIC CLINIC AND 10000.00 N/A CONTRACTUAL N
LABORATORY

(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 N/A N/A N/A N/A

(Continue on separate sheet if necessary)

VII. LEARNING AND DEVELOPMENT (L&D) INTERVENTIONS/TRAINING PROGRAMS ATTENDED
INCLUSIVE DATES OF
30. TITLE OF LEARNING AND DEVELOPMENT INTERVENTIONS/TRAINING PROGRAMS ATTENDANCE Type of LD
NUMBER OF HOURS ( Managerial/ CONDUCTED/ SPONSORED BY
(Write in full) (mm/dd/yyyy) Supervisory/ (Write in full)
Technical/etc)
From To
ORIENTATION OF THE VACCTRACK AS AGGREGRATE DATA COLLECTION 09/19/2024 09/19/2024 3.0 TECHNICAL DEPARTMENT OF HEALTH
TOOL FOR IMMUNIZATION DPCB NIP
DISSEMINATION OF DM 2024-0306 (UPDATED INTERIM GUIDELINES ON THE 09/06/2024 09/06/2024 4.3 TECHNICAL DEPARTMENT OF HEALTH
PREVENTION, DETECTION, AND MANAGEMENT OF MPOX
ADVANCING MATERNAL AND CHILD HEALTH: INNOVATIONS, CHALLENGES 07/20/2024 07/20/2024 8.0 TECHNICAL INTEGRATED MIDWIVES ASSOCIATION OF
AND SOLUTION THE PHILIPPINES
ONLINE ORIENTATION ON TB PREVENTIVE TREATMENT FOR PHYSICIAN AND 07/18/2024 07/18/2024 3.0 TECHNICAL DEPARTMENT OF HEALTH
NURSES

BASIC INTRAVENOUS THERAPY TRAINING 09/29/2023 01/10/2023 18.0 TECHNICAL A. ZARATE GENERAL HOSPITAL

MIDWIVES AS AGENT OF CHANGE GET THROUGH WITH THE CHALLENGES ON 12/17/2021 12/17/2021 5.0 TECHNICAL INTEGRATED MIDWIVES ASSOCIATION OF
THE NEW NORMAL THE PHILIPPINES
CAREER PROGRESSION FOR MIDWIVES: LABAN PARA SA PAGSULONG SA 03/09/2021 03/09/2021 4.0 TECHNICAL PROFESSIONAL MARKETING INSIGHT
PROPESYON
ADVOCATING FOR NUTRITION: SAMA- SAMANG PAGKILOS LABAN SA 07/22/2021 07/22/2021 4.0 TECHNICAL PROFESSIONAL MARKETING INSIGHT
MALNUTRISYON
LABAN NG MIDWIVES PARA SA MAS MATATAG NA HEALTH SYSTEM 06/24/2021 06/24/2021 4.0 TECHNICAL PROFESSIONAL MARKETING INSIGHT
BASIC OCCUPATIONAL SAFETY AND HEALTH TRAINING FOR SAFETY OFFICER 08/06/2021 09/06/2021 10.0 TECHNICAL DEPARTMENT OF LABOR AND EMPLOYMENT
I
PHILIPPINE REDCROSS BASIC LIFE SUPPORT-CPR FOR HEALTHCARE 08/12/2014 08/12/2014 8.0 TECHNICAL PHILIPPINE REDCROSS
PROVIDER

PHILIPPINE REDCROSS STANDARD FIRST AID TRAINING COURSE 08/13/2014 08/13/2014 8.0 TECHNICAL PHILIPPINE REDCROSS

IMAP- PARTOGRAPH MONITORING TOOL FOR THE PROGRESS OF LABOR 12/12/2010 12/13/2010 8.0 TECHNICAL INTEGRATED MIDWIVES ASSOCIATION OF
THE PHILIPPINES

IMAP-ULTARSOUND INTERPRETATION 04/05/2010 04/05/2010 8.0 TECHNICAL INTEGRATED MIDWIVES ASSOCIATION OF

THE PHILIPPINES

(Continue on separate sheet if necessary)

VIII. OTHER INFORMATION

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

FLEXIBLE BEST IN PATIENT CARE HANDLING: STANDARD FIRST AID TRAINING WITH BASIC LIFE N/A
SUPPORT

CAN WORK WITH MINIMIZE SUPERVISION

RESOURCEFUL

TAKING INIATIVE AND HAS A POSITIVE

ATTITUDE

READING BOOKS AND ARTICLES

COMPUTER LITERATE

(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? YES ✘ NO
b. within the fourth degree (for Local Government Unit - Career Employees)? YES ✘ NO
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
by any court or tribunal? YES ✘ NO
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 ✘YES NO
out (abolition) in the public or private sector? If YES, give details:
________________________________
RESIGNATION, END OF CONTRACT
________________________________
38. a. Have you ever been a candidate in a national or local election held within the last year (except
Barangay election)? YES ✘ NO
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
MS. CATHERINE R. GATDULA, RN. MAN. QUEZON CITY, METRO MANILA 0915-310-1159 4.5 cm. X 3.5 cm
(passport size)
MS. DEBBIE ROSE PARANADA, RM. SAN MARCELINO, ZAMBALES 0961-954-6287
Computer generated
or photocopied picture
MS. ANALIZA DALIT, RM. RN. OLONGAPO CITY, ZAMBALES 0930-045-6224 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.: 0843016 Signature (Sign inside the box)

01/15/2025
Date/Place of Issuance: 08/15/2014/ METRO 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