St.

Scholastica’s College Tacloban

College of Nursing & Midwifery
Manlurip, San Jose, Tacloban City
Tel.No. (053) 325-2188 local 201

Name of Student:____________________________________________________________________________________________________________________________________________________________
Name & Address of School:
Accreditation Level: (if any) None Year Granted None
Date School/Program was Recognized: April 11, 2003 Number (GR) 07 Year 2003
First Course (if any): School Graduated From: _______________________Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Prepared by: _______________________

Signature over printed name

I. MAJOR OPERATIONS
No. Date of Case No. Name of Diagnosis Operation Type of Name of Name of Name and Signature of O.R. Scrub Supervised by
Operation Patient Performed Anesthesia Surgeon Hospital Nurse

1 Mr. Maria dela Cruz, RN, MAN

Date Signed: _
Degree: _______________
a) PRC No:___________
Valid Until: ___________
b) PNA No.:_________
Valid Until: ______________

4
 5

NOTED BY: CONCURRED BY: CONCURRED BY:

__________________________________ _________________________________________
Signature over Printed Name of Chief Nurse
Signature over Printed Name of Clinical Coordinator
Eastern Visayas Regional Medical Center
SSCHS, College of Nursing
Date signed:________________________________________
Date signed:______________________________
Degree: ____________________________
Degree: _____________________
a)PRC No.: ________________________________
a)PRC No.: _______________________
Valid Until: __________________________
Valid Until: ______________
b)PNA No.: ___________________________________
b)PNA No.: _______________________
Valid Until: ____________________________
Valid Until: _________________
____________________________________
Signature over Printed Name of Chief Nurse
Divine Word Hospital
Date signed:___________________________________
Degree: ______________________
a)PRC No.: __________________________
Valid Until: _____________________
b)PNA No.: ____________________________
Valid Until: ________________________

APPROVED BY:

______________________________________
Signature over Printed Name of Dean
SSCHS, College of Nursing
Date
signed:_____________________________________
Degree: _____________________
a)PRC No.: ____________________________
Valid Until: _________________________
b)PNA No.: ______________________________
Valid Until: ________________________
c)ADPCN No.: ________________________________
Valid Until: _______________________

I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

Subscribed and sworn before me this _____ day of ___________ 20______, Philippines.
_________________________________
Signature of Applicant
Doc. No. _________________
Page No. _________________
Book No. _________________
Series of: _________________ St. Scholastica’s College Tacloban
College of Nursing & Midwifery
Manlurip, San Jose, Tacloban City
Tel.No. (053) 325-2188 local 201

Name of Student: _______________________________________________________________________________________________________________________________

Name & Address of School:
Accreditation Level: (if any) None Year Granted None
Date School/Program was Recognized: April 11, 2003 Number (GR) 07 Year 2003
First Course (if any): School Graduated From: _______________________Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Prepared by: : Juan dela Cruz

Signature over printed name

II. MINOR OPERATIONS

No. Date of Case No. Name of Diagnosis Operation Type of Name of Surgeon Name of Name of Supervised by
Operation Patient Performed Anesthesia Hospital Nurse on
Duty

3
 4

NOTED BY: CONCURRED BY: CONCURRED BY:

________________________________________
__________________________________ Signature over Printed Name of Chief Nurse
Signature over Printed Name of Clinical Coordinator Eastern Visayas Regional Medical Center
SSCHS, College of Nursing Date signed:________________________________________
Date signed:______________________________ Degree: ____________________________
Degree: _____________________ a)PRC No.: ________________________________
a)PRC No.: _______________________ Valid Until: __________________________
Valid Until: ______________ b)PNA No.: ___________________________________
b)PNA No.: _______________________ Valid Until: ____________________________
Valid Until: _________________
____________________________________
Signature over Printed Name of Chief Nurse
Divine Word Hospital
Date signed:___________________________________
Degree: ______________________
a)PRC No.: __________________________
Valid Until: _____________________
b)PNA No.: ____________________________
Valid Until: ________________________

APPROVED BY:

______________________________________
Signature over Printed Name of Dean
SSCHS, College of Nursing
Date
signed:_____________________________________
Degree: _____________________
a)PRC No.: ____________________________
Valid Until: _________________________
b)PNA No.: ______________________________
Valid Until: ________________________
c)ADPCN No.: ________________________________
Valid Until: _______________________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
 Subscribed and sworn before me this _____ day of ___________ 20______, Philippines.
_________________________________
Signature of Applicant

Doc. No. _________________

Page No. _________________
Book No. _________________
Series of: _________________
St. Scholastica’s College Tacloban
College of Nursing & Midwifery
Manlurip, San Jose, Tacloban City
Tel.No. (053) 325-2188 local 201

Name of Student: _______________________________________________________________________________________________________________________________

Name & Address of School:
Accreditation Level: (if any) None Year Granted None
Date School/Program was Recognized: April 11, 2003 Number (GR) 07 Year 2003
First Course (if any): School Graduated From: Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Prepared by: Juan dela Cruz

Signature over printed name

IV. DELIVERIES ASSISTED

No. Case No. Diagnosis Name of Mother Age of Mother Date of Time of Gender Name of Type of Supervised by
Delivery Delivery of Baby Hospital Delivery

2
 3
NOTED BY:
__________________________________
Signature over Printed Name of Clinical Coordinator
SSCHS, College of Nursing
Date signed:______________________________
Degree: _____________________
a)PRC No.: _______________________
Valid Until: ______________
b)PNA No.: _______________________
Valid Until: _________________
CONCURRED BY: CONCURRED BY:
_________________________________________
Signature over Printed Name of Chief Nurse
Eastern Visayas Regional Medical Center
Date signed:________________________________________
Degree: ____________________________
a)PRC No.: ________________________________
Valid Until: __________________________
b)PNA No.: ___________________________________
Valid Until: ____________________________
____________________________________
Signature over Printed Name of Chief Nurse
Divine Word Hospital
Date signed:___________________________________
Degree: ______________________
a)PRC No.: __________________________
Valid Until: _____________________
b)PNA No.: ____________________________
Valid Until: ________________________
APPROVED BY:
______________________________________
Signature over Printed Name of Dean
SSCHS, College of Nursing
Date
signed:_____________________________________
Degree: _____________________
a)PRC No.: ____________________________
Valid Until: _________________________
b)PNA No.: ______________________________
Valid Until: ________________________
c)ADPCN No.: ________________________________
Valid Until: _______________________
 I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

Subscribed and sworn before me this _____ day of ___________ 20______, Philippines.
_________________________________
Signature of Applicant

Doc. No. _________________

Page No. _________________
Book No. _________________
Series of: ________________

St. Scholastica’s College Tacloban

College of Nursing & Midwifery
Manlurip, San Jose, Tacloban City
Tel.No. (053) 325-2188 local 201

Name of Student: _______________________________________________________________________________________________________________________________

Name & Address of School:
Accreditation Level: (if any) None Year Granted None
Date School/Program was Recognized: April 11, 2003 Number (GR) 07 Year 2003
First Course (if any): School Graduated From: Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Prepared by: Juan dela Cruz

Signature over printed name

III. DELIVERIES HANDLED

No. Case No. Diagnosis Name of Age of Date of Time of Gender of Name of Type of Supervised by
Mother Mother Delivery Delivery Baby Hospital Delivery
 1

NOTED BY: CONCURRED BY: CONCURRED BY:

__________________________________ _________________________________________
Signature over Printed Name of Chief Nurse
Signature over Printed Name of Clinical Coordinator
Eastern Visayas Regional Medical Center
SSCHS, College of Nursing
Date signed:________________________________________
Date signed:______________________________
Degree: ____________________________
Degree: _____________________
a)PRC No.: ________________________________
a)PRC No.: _______________________
Valid Until: __________________________
Valid Until: ______________
b)PNA No.: ___________________________________
b)PNA No.: _______________________
Valid Until: ____________________________
Valid Until: _________________
 ____________________________________
Signature over Printed Name of Chief Nurse
Divine Word Hospital
Date signed:___________________________________
Degree: ______________________
a)PRC No.: __________________________
Valid Until: _____________________
b)PNA No.: ____________________________
Valid Until: ________________________

APPROVED BY:

______________________________________
Signature over Printed Name of Dean
SSCHS, College of Nursing
Date
signed:_____________________________________
Degree: _____________________
a)PRC No.: ____________________________
Valid Until: _________________________
b)PNA No.: ______________________________
Valid Until: ________________________
c)ADPCN No.: ________________________________
Valid Until: _______________________

I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

Subscribed and sworn before me this _____ day of ___________ 20______, Philippines.
_________________________________
Signature of Applicant
Doc. No. _________________
Page No. _________________
Book No. _________________
Series of: _________________

St. Scholastica’s College Tacloban

College of Nursing & Midwifery
Manlurip, San Jose, Tacloban City
Tel.No. (053) 325-2188 local 201

Name of Student: _______________________________________________________________________________________________________________________________

Name & Address of School:
Accreditation Level: (if any) None Year Granted None
Date School/Program was Recognized: April 11, 2003 Number (GR) 07 Year 2003
First Course (if any): School Graduated From: Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Prepared by: Juan dela Cruz

Signature over printed name
 V. CORD DRESSING
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age of Mother Name of Supervised by
Hospital

CONCURRED BY:

_________________________________________
Signature over Printed Name of Chief Nurse
NOTED BY: Eastern Visayas Regional Medical Center CONCURRED BY:
Date signed:________________________________________
Degree: ____________________________
__________________________________ a)PRC No.: ________________________________
Signature over Printed Name of Clinical Coordinator Valid Until: __________________________
SSCHS, College of Nursing b)PNA No.: ___________________________________
Date signed:______________________________ Valid Until: ____________________________
Degree: _____________________
a)PRC No.: _______________________
Valid Until: ______________
b)PNA No.: _______________________
Valid Until: _________________
___________________________________
Signature over Printed Name of Chief Nurse
Divine Word Hospital
Date signed:___________________________________
Degree: ______________________
a)PRC No.: __________________________
Valid Until: _____________________
b)PNA No.: ____________________________
Valid Until: ________________________

APPROVED BY:

______________________________________
Signature over Printed Name of Dean
SSCHS, College of Nursing
Date
signed:_____________________________________
Degree: _____________________
a)PRC No.: ____________________________
Valid Until: _________________________
b)PNA No.: ______________________________
Valid Until: ________________________
c)ADPCN No.: ________________________________
Valid Until: _______________________
I declare under oath that these cases have been
accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of
the Philippines.

Subscribed and sworn before me this _____ day of ___________ 20______, Philippines.
_________________________________
Signature of Applican
Doc. No. _________________
Page No. _________________
Book No. _________________
Series of: _________________