Evaluation tool

DOH evaluation tool for CON general hospitals

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: PASEGURUHAN NG MGA NAGLILINGKOD SA PAMAHALAAN
(GOVERNMENT SERVICE INSURANCE SYSTEM)
Financial Center, Pasay City, Metro Manila 1308

FREEDOM OF INFORMATION REQUEST FORM
(Pursuant to Executive Order No. 2, s. 2016)
(as of November 2016)
A. Requesting Party
Title (e.g. Mr, Mrs, Ms, Miss)

Given Name/s (including M.I)

Surname

Complete Address (Apt/House Number, Street, City /Municipality, Province)

Citizenship

Landline/Fax

Email

Mobile

Preferred Mode of Communication

Landline

Mobile Number

Email

Postal Address

Type of ID Given (Please ensure your IDs contain photo & signature)
Passport

Driver’s License

Voter’s ID

SSS ID

School ID

Company ID

Postal ID
Others

B. Requested Information
Document/Record
Requested (Please be as detailed as
possible)
Period Covered (DD/MM/YY)
Purpose

C. Privacy Notice
The information provided by the GSIS shall not be used for commercial purposes, and shall not be sold or shared to
any person or entity without the consent of the GSIS.

Signature

: __________________________________

Date Accomplished (DD/MM/YYYY)

:___________________________________

D. FOI Receiving Officer [INTERNAL USE ONLY]
Name (Print name)

The request is recommended to be:

Approved

Denied

If Denied, please tick the Reason for the denial:
Invalid Request

Incomplete

Data already available online

Signature

: __________________________________

Date Signed (DD/MM/YYYY)

:___________________________________