Department of Health OFFICE OF THE...

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila ● Trunk Line 651-7800 local 1113, 1108, 1135 Direct Line: 711-9502; 711-9503Fax: 743-1829 ● URL: http://www.doh.gov.ph; e-mail: [email protected]

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jbp/cdmd/hhrdb/16-20

Republic of the Philippines

Department of Health

OFFICE OF THE SECRETARY

Ref. No.

Key Activities Responsibilities Reference

Document / Record

1 ▪ DOH announces the availability of the scholarship grant through the Regional Offices

▪ DOH-HHRDB ▪ DOH-ROs

▪ Department Memorandum

2 ▪ Students shall apply directly to the school and should meet the minimum requirements set by the partner institution Only those who have been admitted to the partner schools are eligible to apply for the DOH scholarship

▪ Partner schools ▪ List of potential scholars

3 ▪ Partner school shall submit the list of potential scholar to DOH for evaluation and approval of the DOH Scholarship Committee Successful scholars shall be notified through the Scholarships Department of the schools

▪ Department

Personnel Order shall be prepared for the Scholars

▪ DOH Scholarship committee

▪ DOH-HHRDB

▪ Department Personnel Order

Announcement of Scholarship

Grant offered

Application and

Screening

Evaluation and approval of successful

scholars

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Ref. No.


Document / Record

4 ▪ Students shall be provided with the Scholarship Contract through the Regional Offices

▪ Partner schools shall sign a MOA with the DOH for the implementation of the grant

▪ DOH-HHRDB and ROs

▪ Scholarship contract for students

▪ Memorandum of Agreement with partner schools

5 ▪ Partner schools shall submit performance reports to the Regional Offices at the end of every school year semester with appropriate recommendations on the scholarship of the students

▪ Regional Offices shall provide updates to HHRDB on the status of the scholarships grant at the end of every school year semester with appropriate recommendations on the scholarship of the students and the performance of the partner schools

▪ Partner school ▪ DOH-RO

▪ Performance reports and recommended actions

6 ▪ Schools shall provide DOH the list of successful graduates and those who have failed to finish the course with complete contact details of the students

▪ Schools shall also provide DOH the list of student who opted to take the board exam and those who did not

▪ Partner school

▪ List of students that graduated

▪ List of board takers ▪ List of board

passers

Signing of Contracts and

MOA

Monitoring of Academic

Performance

Rendering of return service

obligations

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Ref. No.


Document / Record

▪ Schools shall also provide the list of passers and those who have failed the exams

▪ Schools shall coordinate with the scholars to report to the respective Regional Office upon passing the board examination

▪ Students shall render (two) 2 years of service for every one (1) year of scholarship grant

▪ DOH-ROs

List of partner schools from Region I and II for

the DOH Pre Service Scholarship Program Medical Scholarship REGION I University of Northern Philippines REGION II Cagayan State University Midwifery Scholarship REGION I Union Christian College REGION I Urdaneta City University REGION I Eastern Pangasinan University

REGION I Don Mariano Marcos Memorial State

University REGION I North Luzon Philippines State College REGION II Isabela State University REGION II Quirino State University

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cev/cdmd/hhrdb/17-9

SELECTION CRITERIA FOR SCHOLARS

Name of Applicant: ___________________________________________ Date Evaluated: __________

Address: ____________________________________________________

SUMMARY

Category Weight Score

Category 1: Citizenship 5 SCORING:

1st Priority: more than 36

2ndPriority: 25– 35

Not a Priority: less than 25

Category 2: Health Condition 5

Category 3: School Admission 5

Category 4: Residence

4a: GIDA 10

4b: CADT Area/Indigenous Community 10

4c: Municipality Class/ City 5

4d: 20 Poorest Province 5

Category 5: Income (Monthly Gross) 10

Category 6: Affiliation 5

Total 60

CATEGORY 1: CITIZENSHIP

Criteria Weight Score

Filipino 5

Non- Filipino 0

Total

CATEGORY 2: HEALTH CONDITION


Physically and mentally fit 5

With illness 0

Total

CATEGORY 3: SCHOOL ADMISSION


Passed 5

Declined 0

Total

CATEGORY 4: RESIDENCE

Category 4a: Geographically Isolated and Disadvantaged Areas (GIDA)


GIDA 10

Non- GIDA 0

Total

Category 4b: Certificate of Ancestral Domain Title (CADT) Area/Indigenous Community


CADT Area/Indigenous Community 10

Non- CADT Area/ Non- Indigenous Area 0

Total

Category 4c: Municipality Class/ City


Sixth Class 5

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cev/cdmd/hhrdb/17-9


Fifth Class 4

Fourth Class 3

Third Class 2

Second Class 1

First Class 0

City 0

Total

Category 4d: 20 Poorest Province


Lanao del Sur (ARMM) 5

Maguindanao (ARMM) 5

Sulu (ARMM) 5

Mt. Province (CAR) 5

Agusan del Sur (Caraga) 5

Catanduanes (Region 5) 5

Sorsogon (Region 5) 5

Negros Oriental (Region 7) 5

Siquijor (Region 7) 5

Eastern Samar (Region 8) 5

Leyte (Region 8) 5

Northern Samar (Region 8) 5

Western Samar (Region 8) 5

Zamboanga del Norte (Region 9) 5

Zamboanga Sibugay (Region 9) 5

Bukidnon (Region 10) 5

Lanao del Norte (Region 10) 5

North Cotabato (Region 12) 5

Sarangani (Region 12) 5

Sultan Kudarat (Region 12) 5

Total

CATEGORY 5: INCOME (COMBINED MONTHLY GROSS FAMILY)


Php 30,000.00 per family member 0

Php 20,000.00 – 29,999.00 per family member 5

<Php19,999.00 per family member 10

Total

CATEGORY 6: AFFILIATION


Member of Minority Sector (e.g.Manobo, Aeta, Mangyan, Tausug, Maranao, Badjao, etc) 5

Dependent of Government Employee 5

Dependent of Barangay Health Worker 5

Dependent of Traditional Birth Attendant 5

Dependent of Police/ Soldier Fatally Wounded/ Killed on Duty 5

Victim of Calamities/ insurgencies 5

Total

Evaluated by: Noted by:

__________________________ ___________________________________

<NAME> <NAME>

Position/Designation Regional Director

Republic of the Philippines

Department of Health

DOH SCHOLARSHIP PROGRAM

APPLICATION FORM

Print legibly and use separate sheet if necessary. Place marks in appropriate boxes. Only accomplished application forms will be processed.

SCHOLARSHIP APPLIED FOR:

Medical Scholarship Program

Midwifery Scholarship Program

PERSONAL BACKGROUND [ ] Member of Ethnic Minority or Indigenous People

Specify:_____________________

[ ] Barangay Health Worker – Child

[ ] Traditional Birth Attendant - Child

[ ] Government Staff – Child

[ ] Victim of Calamity/ Insurgency

NAME:

(Surname)

(First Name)

(Middle Name)

DATE OF BIRTH:

PLACE OF BIRTH:

AGE: GENDER:

[ ]Female

[ ]Male

CIVIL STATUS:

[ ] Singe [ ] Widowed

[ ] Married [ ] Separated

NATIONALITY: Religious Affinity:

PERMANENT ADDRESS: Tel #:

MAILING ADDRESS:

Tel #:

CELLPHONE # (if any)

E-MAIL ADDRESS: (if any)

TIN #:

Philhealth # (if any)

LBP Account: (if any)

LBP Branch:

FAMILY BACKGROUND Father’s Name:

Age: Occupation: Salary:

Mother’s Name:


Spouse’s Name:


Number of siblings ______

Sibling Rank ______

Gross Monthly Family

Income:

Names of Children:

__________________________

__________________________

__________________________

Age(s)

__________

__________

__________

______

EDUCATIONAL BACKGROUND

LEVEL NAME OF SCHOOL

HIGHEST GRADE

FINISHED OR

DEGREE EARNED

INCLUSIVE

DATES OF

ATTENDANCE

SCHOLARSHIP/

HONOR(S) /

DISTINCTION

RECEIVED From To

ELEMENTARY

SECONDARY

VOCATIONAL /

TRADE COURSE

COLLEGE

GRADUATE

STUDIES

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Paste a recent 1” x 1” photograph (taken

within the last 6 months)

in this box.

EMPLOYMENT / SERVICE RECORD (Start from current work)

POSITION TITLE OFFICE/COMPANY INCLUSIVE

DATES

STATUS OF

EMPLOYMENT

MONTHLY

SALARY

REFERENCES

Please provide at least two (2) character references you are not related to.

NAME POSITION & ADDRESS CONTACT NO.

I declare that all information and documents submitted with this application form are true and correct 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 trust that this

information shall remain confidential.

_____________________________

Applicant’s Signature over

Printed Name

__________________________

Date

Attachments:

1. Copy of Barangay Certification/ Certification of a Bona Fide Resident of the Community

2. Copy of Combined Family Income Tax Return (ITR)

3. Certificate of Indigency (if applicable)

4. Certification from National Commission on Indigenous Peoples (NCIP) (if applicable)

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