PERSONAL DATA SHEET

CS ID NO.
I. PERSONAL INFORMATION
2. SURNAME LAGAT
FIRST NAME LUDIVINO
MIDDLE NAME JOSUE 3. NAME EXTENSION (e.g. Jr., Sr.)
4. DATE OF BIRTH (mm/dd/year) 04/14/58
5. PLACE OF BIRTH
DINGRAS, ILOCOS 219A 2ND STREET, DOLORES HOMESITE, CITY
16. RESIDENTIAL ADDRESS
NORTE OF SAN FERNANDO, PAMPANGA
6. SEX X MALE

ZIP CODE
7. CIVIL STATUS
Single Widowed 17. TELEPHONE NUMBER

Married Separated Same as above.

18. PERMANENT ADDRESS

Annulled Other

8. CITIZENSHIP FILIPINO ZIP CODE

9. HEIGHT (m) 1.7 19. TELEPHONE NUMBER
10. WEIGHT (kg) 95.256
11. BLOOD TYPE “A” 20. EMAIL ADDRESS [email protected]
12. GSIS ID NO. 21. CELLPHONE NUMBER 0917 549 8463
13. PAG-IBIG ID NO.
O7O137942208 / 0004-
003487-09(old)
14. PHILHEALTH NO.
026375648 / 19- 22. AGENCY EMPLOYEE NO.
0406
000175444-4(old)
15. SSS NO. 0387460075 23. TIN 125 830 566
II. FAMILY BACKGROUND
24. SPOUSE’S SURNAME LAGAT 25. NAME OF CHILDREN DATE OF BIRTH
FIRST NAME ESTHER LUTHER CLARKE M. LAGAT 02/04/83
MIDDLE NAME MACAGBA EMIL PETER M. LAGAT 04/21/84
OCCUPATION ANESTHESIOLOGIST
EMPLOYER / BUSINESS (ON-CALL/PRIVATE PRACTICE)
NAME

BUSINESS ADDRESS
TELEPHONE NUMBER
26. FATHER’S SURNAME LAGAT
EMILIO
FIRST NAME
MIDDLE NAME ORIFON
27. MOTHER’S MAIDEN
SURNAME JOSUE
FIRST NAME FLORA
MIDDLE NAME RANJO
III. EDUCATIONAL BACKGROUND
HIGHEST INCLUSIVE DATES OF SCHOLARSHIPS /
YEAR
DEGREE GRADE LEVEL / ATTENDANCE ACADEMIC
28. LEVEL NAME OF SCHOOL GRADUATE
COURSE UNITS EARNED HONORS
D FROM TO
(if not graduated) ACHIEVED
MANDALOQUE ELEMENTARY 1972
ELEMENTARY
SCHOOL
DIVINE WORL COLLEGE, HIGH 1976
SECONDARY
SCHOOL DEPT.
 VOCATIONAL /
TRADE SCHOOL

BACHELOR
OF
SCIENCE
SAN JUAN DE DIOS COLLEGE IN 1980
MEDICAL
COLLEGE
TECHNOLO
GY
BACHELOR 2003
OF
SAINT DOMINIC SAVIO
COLLEGE
SCIENCE
IN
NURSING

DOCTOR
LYCEUM NORTHWESTERN
OF 1984
FQDMF, COLLEGE OF MEDICINE
GRADUATE STUDIES MEDICINE

CS FORM 212 (Revised 2005) Page 1 0f 4

IV. CIVIL SERVICE ELIGIBILITY
DATE OF LICENSE
29. CAREER SERVICE / RA 1080 (BOARD/BAR) UNDER PLACE OF EXAMINATION /
RATING EXAMINATION / DATE OF
SPECIAL LAWS / CES / CSEE CONFERMENT NUMBER
CONFERMENT RELEASE
PHYSICIANS LICENSURE 12/09/19
PASSED MANILA 0061146
EXAMINATION 86
01/05/20
NURSING EXAMINATION PASSED MANILA 0354822
04

V. WORK EXPERIENCE (Include private employment. Start from your current work)
30. INCLUSIVE DATES SALARY GOVER
(mm/dd/year) GRADE & NMENT
POSITION / TITLE (write in DEPARTMENT / AGENCY / OFFICE / COMPANY MONTHLY STATUS OF
STEP SERVIC
full) (write in full) SALARY APPOINTMENT
FROM TO INCREM E
ENT (Yes/No)
MEDICO-
03/11/2 LEGAL
PRESE COMMISSION ON HUMAN RIGHTS 22 PERMANENT YES
011 OFFICER
NT
III
03/-- 06/-- STAFF CENTINELA HOSPITAL AND
PERMANENT NO
2007 2007 NURSE MEDICAL CENTER, LOS ANGELES
DEPARTMENT OF JUSTICE,
MEDICAL
03/--/19 08/--/20 NATIONAL BUREAU OF
SPECIALIS 23 PERMANENT YES
92 07 INVESTIGATION, MEDICO-LEGAL
T III
DIVISION
RESIDENT
RIZAL MEDICAL CENTER, PASIG
1987 1992 PHYSICIA TEMPORAY YES
CITY
N
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CS FORM 212 (Revised 2005) Page 2 0f 4

VI. VOLUNTARY WORK OR INVOLVEMENT IN CIVIC / NON-GOVERNMENT/ PEOPLE /

VOLUNTARY ORGANIZATIONS
INCLUSIVE DATES NUMBER OF POSITION / NATURE OF
31. NAME & ADDRESS OF ORGANIZATION (write in full)
FROM TO HOURS WORK

Rotary International, Cubao South East

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VII. TRAINING PROGRAMS (Start with the most recent training.)
INCLUSIVE DATES CONDUCTED /
NUMBER OF
32. TITLE OF SEMINAR / CONFERENCE / WORKSHOP / SHORT COURSE (write in full) SPONSORED BY (write in
FROM TO HOURS
full)
DNA ANALYSIS
BONE DNA WORKSHOP FOR HUMAN REMAINS 01/12/2015. 01/14/2015
01/20/2015 01/23/2015 LABORATORY.
IDENTIFICATION
NSRI,UP
FORENSIC PHOTOGRAPHY WORKSHOP 01/09/2015 CHR
BASIC DIGITAL PHOTOGRAPHY WORKSHOP 01/08/2015 CHR
WORKSHOP ON HUMAN RIGHTS BASED APPROACH TO
02/12/2015 02/13/2015 CHR
PRISON MANAGEMENT
HUMAN RIGHTS BASED APPROACH TO DISASTER
07/14/2014 07/18/2014 CHR
MANAGEMENT
FORENSIC CONFERENCE FOR HUMAN RIGHTS AND JUSTICE 07/22/2014 07/24/2014 CHR
1ST GLOBAL TERRORISM AND CBRNE 03/04/2014 03/07/2014 CHR
--- 2013 DOWN- REFER TO OLD PDS---
Security Awarenes 6/28/18 CHR
Investigation and Documentation of EJK 8/9/17 8/11/17 CHR R3
Planning Workshop for 2019 5/25/18 5/26/18 Ciudad Christhia
Phil. Cultural
19th Conf. on Psychosocial Rehab. 11/27/18 11/28/18
College
June 4,
The Future of Forensic Data Base in the Phil. PNP
2019
More on file

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VIII. OTHER INFORMATION
34. NON-ACADEMIC DISTINCTIONS / RECOGNITIONS 35. MEMBERSHIP IN ASSOCIATIONS /
33. SPECIAL SKILLS / HOBBIES
(write in full) ORGANIZATIONS (write in full)

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CS FORM 212 (Revised 2005) Page 3 0f 4

36. Are you related by consanguinity or affinity to any of the following:

a) Within the Third Degree (for National Government Employees): ___ YES __X_ NO
Appointing authority, recommending authority, chief of office / bureau / department or person who has immediate supervision If YES, give details:
over you in the Office, Bureau or department where you will be appointed?

b) Within the Fourth Degree (for Local Government Employees): ___ YES ___X NO
Appointing or recommending authority where you will be appointed? If YES, give details:

37. a) Have you ever been formally charged? ___ YES _X__ NO
If YES, give details:

37. b) Have you ever been found guilty of any administrative offense? ___ YES __X_ NO
If YES, give details:

38. Have you ever been convicted of any crime or violation of any law, decree, ordinance or regulation by any court or tribunal? ___ YES ___X NO
If YES, give details:

39. Have you ever been separated from the service in any of the following modes: resignation, retirement, dropped from the rolls, ___X YES ___ NO
dismissed, termination, end of term, finished contract, AWOL or phased out, in the public or private sector? If YES, give details:

OPTIONAL RETIREMENT. I have to go to the US to

attend to my sister and brother-in-law who had several
fractures due to vehicular accident.
40. Have you ever been a candidate in a national or local election (except Barangay election)? ___ YES _X__ NO
If YES, give details:

41. Pursuant to: (a) the Indigenous peoples Act (RA 8371); (b) Magna Carta for Disabled Persons (RA 7277); and (c) the Solo Parent
Welfare Act of 2000 (RA 8972), please answer the following items:

a) Are you a member of any indigenous group? ___ YES ___X NO

If YES, please specify:
_____________________________
b) Are you differently abled?
___ YES __x_ NO
If YES, please specify:
c) Are you a solo parent? _____________________________

___ YES __x_ NO

If YES, please specify:
_____________________________

42. REFERENCES (Person not related by consanguinity or affinity to applicant / appointee)

NAME ADDRESS TELEPHONE NUMBER

SEC. ARSENIO BALISACAN PCC

DR. JOSEPH ANDREW
FORENSIC CENTER, CHR
JIMENEZ
DR. RONALD RAVELL
FORENSIC CENTER, CHR
BALUYOT
43. I declare under oath that this Personal Data Sheet has been accomplished by me, and is a true, correct and complete statement pursuant to the provisions of
pertinent laws, rules and regulations of the Republic of the Philippines.

I also authorize the agency head / authorized representative to verify / validate the contents stated herein. I trust that the information shall remain confidential.

PHOTO

27826727
COMMUNITY TAX CERTIFICATE NUMBER

SAN FERNANDO, PAMPANGA

ISSUED AT SIGNATURE (SIGN INSIDE THE BOX)

01/06/2020 02/10/2020
ISSUED ON (mm/dd/year) DATE ACCOMPLISHED RIGHT THUMBMARK

CS FORM 212 (Revised 2005) Page 4 0f 4