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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)
:___________________________________
