TESDA-OP-CO-05-F26

Rev. 00 – 03/01/17

TECHNICAL EDUCATION AND SKILLS DEVELOPMENT AUTHORITY

PangasiwaansaEdukasyongTeknikal at Pagpapaunlad ng Kasanayan

APPLICATION FORM
REFERENCE NUMBER :
Qual – YY Region Province Number Series Number Series
alpha
Assigned to AC
code
PICTURE

UNIQUE LEARNERS IDENTIFIER (ULI): colored,

- - - - passport
size,
to be filled – out by the Processing Officer

Applicant’s Signature Date of Application

Name of School/Training Center/Company: Holy Trinity College


Address: General Santos City
Title of Assessment applied for: Health Care Services NCII
Full Qualification COC Renewal
1. Client Type
TVET Graduating Student TVET graduate Industry worker K-12 OWF

2. Profile
2.1. Name:

SURNAME
FIRSTNAME
MIDDLE NAME MIDDLE INITIAL
NAME EXTENSION
(e.g. Jr., Sr.)

Mailing
2.2.
Address:
Number, Street Barangay District

City Province Region Zip Code

2.3. Mother’s Name 2.4. Father’s Name
2.5.Sex 2.6.Civil Status 2.7. Contact Number(s) 2.8.Highest Educational 2.9.Employment Status
Attainment
Male Single Tel: Elementary Graduate Casual

Female Married Mobile: High School Graduate Job Order

Widow/er E-mail: TVET Graduate Probationary

 Separated Fax: College Level Permanent

College Graduate Self - Employed

Others:
Others: ____________ OFW

2.10 Birth date (mm/dd/yy): M M D D Y Y 2.11 Birth place: 2.12 Age:

3. Work Experience (National Qualification-related)

3.1. 3.2. 3.3. 3.4. 3.5. 3.6

Monthly No. of Yrs.
Name of Company Position Inclusive Dates Status of Appointment
Salary Working Exp.

(For more information, please use separate sheet)

4. Other Training/Seminars Attended (National Qualification-related)

4.1. 4.2. 4.3. 4.4 4.5
Title Venue Inclusive Dates No. of Hours Conducted By

(For more information, please use separate sheet)

5. Licensure Examination(s) Passed

5.1. 5.2. 5.3. 5.4. 5.5. 5.6.
Title Year Taken Examination Venue Rating Remarks Expiry Date

(For more information, please use separate sheet)

6. Competency Assessment(s) Passed

6.1. 6.2. 6.3 6.4. 6.5. 6.6.
Qualification
Title Level Industry Sector Certificate Number Date of Issuance Expiration Date

(For more information, , please use separate sheet)


ADMISSION SLIP

REFERENCE NUMBER
:

Name of Applicant: PICTURE

Tel. Number:

Assessment Applied for: Official Receipt Number:

(Passport
Date Issued:
To be accomplished by the Processing Officer size)
Name of Assessment Center:
 Check submitted requirements: Remarks:

Accomplished Self-Assessment Guide Bring own Personal Protective Equipment

Three (3) pieces colored passport size pictures

Others. Pls. specify

Assessment Date: Assessment Time:

Printed Name & Signature of Processing Officer Printed Name & Signature of Applicant

Date: Date:

Note: Please bring this Admission Slip on your assessment date.

TESDA-OP-QSO-02-F07
Rev.No.00-03/01/17
Reference No.
to be filled out by the Processing Officer
SELF ASSESSMENT GUIDE
Qualification:
Units of Competency Covered:
Instruction:
Read each of the questions in the left-hand column of the chart.
Place a check in the appropriate box opposite each question to indicate your answer.
Can I? YES NO
Basic Competencies
1. Participate in workplace communication
L.O.1. Obtain and convey workplace information

L.O.2. Complete relevant work related documents

L.O.3. Participate in workplace meeting and discussion
 2. Work in a team environment
L.O.1. Describe and identify team role and responsibility in a team

L.O.2. Describe work as a team member

3. Practice career professionalism
L.O.1. Integrate personal objectives with organizational goals
L.O.2. Set and meet work priorities
L.O.3. Maintain professional growth and development
4. Practice occupational health and safety
L. O. 1. Evaluate hazard and risks
L. O.2. Control hazards and risks
L. O.3. Maintain occupational health and safety awareness
COMMON COMPETENCIES
1.Implement and monitor infection control policies and procedures
L.O.1. Provide information to the work group about the organization’s
infection control policies and procedure
L.O.2. Integrate the organization’s infection control policy and
procedures into work practice.
2. Respond Effectively to Difficult/ Challenging Behavior
L.O.1. Identify types of difficult and challenging behavior of patients
L.O.2. Plan responses to maximize availability of appropriate staff and
resources
L.O.3. Respond to difficult or challenging behaviors following
established policies and procedures
L.O.4. Apply response and refer to appropriate health professional
when required
L.O.5. Prepare report and review incidents to appropriate staff
3. Apply Basic First Aid
L.O.1. Explain OSH legislation and regulations
L.O.2. Assess and monitor physical condition of the casualty
L.O.3. Describe different types of injuries
L.O.4. Identify physical hazard, immediate risks and casualty’s vital
signs
L. O.5. Respond and apply immediate and appropriate basic life
support measures
L. O.6. Respond/dealt with complex casualties or incident when
required
L.O.7. Prepare equipment and other resources for basic first aid
application
L.O.8. Communicate details of the incident using relevant
communication media and equipment
L.O.9. Prepare timely report to concerned personnel
4. Maintain High Standards of Patient Services
L.O.1. Provide information to the work group about the organization’s
infection control policies and procedure
L.O.2. Integrate the organization’s infection control policy and
procedures into work practice.
L.O.3.Establish and maintain good interpersonal relationship with
patients
L.O.4. Apply Professional work ethics in dealing with patients
L.O.5. Conduct work performance evaluation
CORE COMPETENCIES
1.Prepare and maintain beds
L.O.1 Prepare the area for bed making
L.O.2 Perform bed making according to established institution
procedures
L.O.3. Perform after care activities of materials and equipment used
2. Collect and maintain linen stocks at end-user location
L.O.1. Explain the workplace procedure in collecting soiled linen
L.O.2. Maintain linen stock levels
L.O.3. Collect soiled linen
L. O.4.Distribute clean linen
3. Assist with patient mobility
L.O.1 Prepare to assist with patient mobility
L.O. 2 Assist with patient mobility
L.O.3 Complete patient mobility assistance
4. Assist in transporting patient
L.O1Explain the workplace procedures in assisting patient transport
L.O.2 Prepare patient for transport
 L.O.4. Perform post-transport care
5. Assist with bio-psychosocial care of patient
L.O.1. Explain the concept of bio-psycho-social support
L.O.2. Assist the patient in verbalizing his perceived problems related
to bio-psycho-social concerns
L.O.3. Perform bio-psycho-social measures and procedures
___________________________________ Date:
implemented in the institution
Candidate’s Name & Signature
L.O.4.Educate the patient on alternatives on healthy bio-psycho-social
Evaluated by:
well-being.  Qualified for Assessment
6. Handle waste in a health care environment
_______________________________
L.O.1Explain the concepts and principles of waste management and
 Not yet Qualified for
safe handling AC Manager
Assessment
L.O.2 Determine job requirements
Date:
L.O.3 Identify and segregate waste
L.O.4 Transport and store waste
L.O.5 Conduct quality control activities on cleanup work areas

TESDA-OP-CO-05-F31
Rev.No.00-03/08/17

Technical Education and Skills Development Authority

ASSESSMENT AND CERTIFICATION PROGRAM

ATTENDANCE SHEET

Health Care Services NC II

Name of Competency Holy Trinity College

Assessment Center:
Date of Assessment: July 29, 2019

No. CANDIDATE’S NAME Reference Number: Signature Assessment Results

Samantha Talaba
Mae Solano
Assessor/s:
TESDA Representative:
__________________________________
Signature over Printed Name ______________________________
Signature over Printed Name
Accreditation Number:_______________
AC Manager:
__________________________________
Signature over Printed Name
______________________________
Accreditation Number:_______________ Signature over Printed Name
 TESDA-OP-CO-05-F28
Rev.No.00-03/08/17

Technical Education and Skills Development Authority

ASSESSMENT AND CERTIFICATION PROGRAM

LETTER OF APPOINTMENT

_______________
Date
___________________
___________________
___________________

Dear Sir/Madam:

 This letter officially appoints you as competency assessor on ______________

(schedule of assessment) (state title of Qualification)
for _______________________________
( name and address of assessment center )center)
at ________________________. Please
report to the Assessment Center as scheduled.

(contact person) (phone number)

If you have any questions, please call _____________ at _______________.
We look forward to your acceptance of this appointment.

Very truly yours,

______________________
AC Manager

Conforme:

_____________________
Signature of Assessor
 TESDA-OP-CO-05-F30
Rev.No.00-03/08/17

REQUEST FORM FOR ASSESSMENT PACKAGE/S

TITLE OF QUALIFICATION

NAME OF ASSESSMENTCENTER

DATE OF ASSESSMENT

NUMBER OF CANDIDATES FOR

ASSESSMENT

REQUESTED BY
 (PO CAC Focal)

DATE OF REQUEST

APPROVED BY
(Provincial Director)

DATE APPROVED

TESDA-OP-CO-05-F29
 Rev.No.00-03/08/17

LETTER OF ASSIGNMENT

_________________
Date

___________________
___________________
___________________

___________________:

This letter officially designates you as TESDA Representative on (__Date __) for
___________________at ___________________. Please report to the Assessment
 Center/Venue as scheduled.

If you have any questions/ queries, please call the undersigned at telephone
number/s ______________.

Very truly yours,

____________________
Provincial Director

Conforme:

_____________________
Signature over printed name
of TESDA Representative

TESDA-OP-CO-05-F34
 Rev.No.00-03/08/17

REPORT ON ASSESSMENTPROCEEDINGS
Name of Competency
Assessment Center
Accreditation Number
Title of Qualification
Date of Assessment No. of Candidates
Name of Competency Assessor
Findings and Observations:
Items Yes No Areas for Improvement
Competency Assessor has a signed Letter of Appointment

Attendance of the candidates is checked and Admission Slips are

verified and collected

Supplies and materials are available during the conduct of assessment

Tools and equipment are available and in good working conditions

Assessment starts on time


Conduct of assessment is in accordance with the methods identified in
the CATs
Projects produced by the candidates are in accordance with the
requirements in the CATs.
Candidates are provided with clear and constructive feedback on the
assessment decision (one-on-one)
Assessor has the ability to manage the competency assessment
proceedings
Complaints of candidates are properly addressed and handled by the
Assessor & the AC, when applicable
Assessment Packages issued to the Assessor are completely returned
upon completion of assessment
Assessment-related documents are accurately accomplished and
submitted promptly after assessment
Rating Sheets
CARS
Attendance Sheet
RWAC
Application Forms with SAGs
Assessor’s Guide & Specific Instruction to Candidate
Narrative: (Recommended areas for improvement of items which are not covered or
named above)

Prepared by: Date:

____________________________________ _____________________
Signature over Printed Name (TESDA Rep)
ESDA-OP-CO-05-F35
Rev.No.00-03/08/17
LETTER OF DESIGNATION
_______________
Date
(Head of TVI/ Company)________
___________________
___________________

Dear ________________:

This letter officially designates ___________________ as assessment venue for

__________________ on __________________. Conduct of assessment shall be
governed by Procedures Manual on Competency Assessment.
We look forward to your acceptance of this agreement.
Very truly yours, Approved by:

___________________ _____________________
AC Manager TESDA Provincial Director

CONFORME:

___________________
Head, TVI/ Company

TESDA-OP-CO-05-F37
Rev.No.00-03/08/17
Performance Evaluation Instrument
Assessor’s Name
Qualification
Date
Name of Respondent Accomplishe
d
[Pls. Tick () where applicable]
ACAC Manager Candidate
INSTRUCTIONS: Put a tick () mark in the appropriate column
5– Very Satisfactory 3 – Good
SCALE GUIDE 1 – Poor
4 – Satisfactory 2 – Fair
RATING
ITEM
5 4 3 2 1
Physical appearance and composure
(Pangkalahatanganyongpisikal at kung paanomagdalasasarili)
Ability to pace instruction
(Kakayahangmagpaliwanag ng malumanay at mahusay kung
anoangmgadapatgawin)
Ability to establish good rapport with candidates
(Kakayahangmagpadaloy ng komunikasyonsapagitanniya at
ng mgakukuha ng pagsusulit)
Ability to ensure that the candidate understands the instruction
(Kakayahangsiguraduhinganglahat ng instruksyon ay
naiintindihan ng mgakukuha ng pagsusulit)
Ability to answer querries, comments, etc.
(Kakayahangmagbigay ng karapatdapatnasagot o
tugonsamgatanong, puna o mgapaglilinaw)
Ability to establish the assessment context and purpose of
assessment
(Kakayahangmagpaliwanagtungkolsalayunin ng
pagsusulit)
Ability to plan and prepare the evidence gathering process
(Kakayahangpaghandaan at
iayosangmgapangangailangansa
pagsusulit)
Ability to provide allowable/reasonable adjustments in the
assessment procedure
(Kakayahangmagbigay ng makabuluhangkonsiderasyonsa
may
Mgapangangailangansapagsusulit)
Ability to conduct assessment in accordance with the methodologies
(Kakayahangipatupadangpagsusulitayonsamgaitinakdang
panuntunan)
Ability to collect appropriate evidence during the conduct of
assessment
(Kakayahangmangalap at sumuri ng mgatamangebidensya
habangnagbibigay ng pagsusulit
Ability to provide clear and constructive feedback on the
assessment decision
(Kakayahangmagbigay ng malinaw at
tamangkaukulangopinyon
saresulta ng pagsusulit)
Ability to provide fair, reliable and valid assessment decision
(Kakayahangmagbigay ng pantay, ugma at
tamangdesisyonsaresulta ng pagsusulit)
Sub - score
FINAL RATING
Signature of Respondent

FOR TESDA USE ONLY

EVALUATOR’S REMARKS:

RECOMMENDATION:
YES
For re-accreditation For further review
NO
*Frequency
For AC Manager – once a month
For Candidate - at least 2 candidates per assessment schedule

TESDA-OP-CO-05-F27
Rev.No.00-03/08/17
LETTER OF AUTHORIZATION

I, ________________________, of legal age, Filipino, single/married with

address at____________________________________, do hereby name, constitute
and appoint _____________________________ of legal age, Filipino, single/ married
and with address at ____________________________________, to be my true
and lawful attorney, for me and in my name, place and stead, to perform the
following acts and things, to wit:
To claim myCertificate in __________________________________; and
To sign all documents necessary for the conduct of said transaction.

Issued on ___________________, 20____ at _____________________.

__________________________
Signature of the Certified Worker

__________________________
Authorized Representative (Signature over Printed Name)
___________________________________________________________________
For TESDA use only

I hereby attest that the claimant presented the following:

Original copy of CARS

Photocopy of ID of the certified worker
Accreditation ID of claimant (if Liaison Officer)
Photocopy ID of claimant

__________________________________
TESDA PO CAC Focal person
(Signature over Printed Name)

TESDA-SOP-CACO-07-F23
Technical Education and Skills Development Authority
ASSESSMENT AND CERTIFICATION PROGRAM

ATTENDANCE SHEET

Health Care Services NC II

Name of Competency
Assessment Center:

Date of Assessment:
Assessment
No. CANDIDATE’S NAME Signature Results
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Assessor/s: TESDA Representative:

Accreditation Number: Signature over Printed Name

CAC Manager:

Signature over Printed Name

Accreditation Signature over Printed Name

TESDA-SOP-CACO-07-F28
 REFERENCE NUMBER

To be filled out by the Competency Assessor

COMPETENCY ASSESSMENT RESULTS SUMMARY

Candidate’s Name:
Assessor’s Name:
Title of Qualification / HEALTH CARE SERVICES NC II
Cluster of Center:
Assessment Date:
The performance of the candidate in the following SatisfactoryNot
unit(s)
Unit of of competency and corresponding
Competency methods
Assessment Method Satisfactory

1.Prepare and Maintain Demonstration

Beds Oral Interview
2.Collect and Maintain Demonstration
Linen Stocks at End-Users Questioning
Oral Interview
Location
3.Assist Mobility Demonstration with Oral
Questioning
Interview
4.Assist Transporting Demonstration with Oral
Patient Questioning
Interview
5.Assist in Bio- Demonstration with Oral
Psychological Questioning
Interview
Support
6. HandleCare of Patients
Waste in a Demonstration with Oral
Health Care Questioning
Interview
Environment
Note: Satisfactory Performance shall only be given to candidate who
demonstrated successfully all the competencies identified in the above-named
Recommendatio  For issuance of  For submission  For re-
n: NC/COC of additional assessment (pls.
(Indicate title of documents specify)
COC, if full Specify:
_

Did the candidate overall performance meet the required  

evidences/standards? YES NO

 Competent  Not Yet Competent

OVERALL EVALUATION
General Comments [Strengths/Improvements needed]
Candidate’s Signature: Date:
Assessor’s Signature: Date:
Assessment Center Manager Date:
Signature:
TESDA-SOP-CACO-07-F28

CANDIDATE’S COPY

(Please present this form when you file and claim your NC/COC)

To be filled out by the Competency Assessor

COMPETENCY ASSESSMENT RESULTS SUMMARY

Name of Candidate: Date:

Name of Assessment
Center: Date:
 Not Yet Competent
Assessment Results:  Competent
 For issuance of  For submission  For re-
NC/COC of additional assessment
Recommendati (Indicate title of documents (pls. specify)
on: COC, if full Specify:
Qualification is not
met)

REFERENCE
NUMBER

Assessed Attested by:

by: Name and Signature Name and Signature

Date: Date:
SELF ASSESSMENT GUIDE

Qualification: HEALTH CARE SERVICES NCII

Project: PROVIDE HEALTH CARE SERVICES TO PATIENTS

Units of Competency • Prepare and Maintain Beds
Covered: • Collect and Maintain Linen Stocks at End-Users
Location
• Assist in Patient Mobility
• Assist in Transporting Patients
• Assist in Bio-Psychological Support Care of Patients
Instruction:
• Read each of the questions in the left-hand column of the chart.
• Place a check in the appropriate box opposite each question to indicate
CAN I? YES NO

• Prepare area for bed making*

• Make up bed*
• Perform after care activities of tools, materials and
equipment that I used*

• Collect soiled linen*

• Distribute clean linen*

• Maintain linen stock level*

• Prepare to assist with patient mobility*

• Assist with patient mobility*

• Complete patient mobility assistance*

• Prepare patient for transport*

• Assist in patient transport*

• Perform post transport procedures*

• Establish and maintain rapport with the patient*

• Obtain information regarding the bio-psychosocial
needs of the patient*
• Provide assistance to meet patient needs as directed
by a health professional*

• Determine job requirements related to waste handling

in a health care environment*

• Identify and segregate waste*

• Transport waste and store in an enclosed and secured

• Conduct quality control activities related to waste
handling in a health care environment

• Clean up work areas in a health care environment

I agree to undertake assessment in the knowledge that information gathered
will only be used for professional development purpose and can only be
assessed by concerned assessment personnel and may manager / supervisor.

Candidate’s signature: Date:

 RATING SHEET

Qualification: HEALTH CARE SERVICES NCII

Project: PROVIDE HEALTH CARE SERVICES TO PATIENTS
Units of • Prepare and Maintain Beds
Competency • Collect and Maintain Linen Stocks at End-Users Location
Covered: • Assist in Patient Mobility
• Assist in Transporting Patients
• Assist in Bio-Psychological Support Care of Patients
• Handle Waste in a Health Care Environment
Instruction:
• Read each of the questions in the left-hand column of the chart.
• Place a check in the appropriate box opposite each question to indicate your
answer.
CAN I? YES NO N/A
• Prepare area for bed making*

• Make up bed*
• Perform after care activities of tools, materials and
equipment that I used*

• Collect soiled linen*

• Distribute clean linen*

• Maintain linen stock level*

• Prepare to assist with patient mobility*

• Assist with patient mobility*

• Complete patient mobility assistance*

• Prepare patient for transport*

• Assist in patient transport*

• Perform post transport procedures*

• Establish and maintain rapport with the patient*

• Obtain information regarding the bio-psychosocial
needs of the patient*
• Provide assistance to meet patient needs as directed
by a health professional*
• Determine job requirements related to waste handling
in a health care environment*

• Identify and segregate waste*

• Transport waste and store in an enclosed and secured

• Conduct quality control activities related to waste
handling in a health care environment

• Clean up work areas in a health care environment

I agree to undertake assessment in the knowledge that information gathered
will only be used for professional development purpose and can only be
assessed by concerned assessment personnel and may manager / supervisor.

Candidate’s signature: Date: