CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

COLLEGE OF NURSING
N. Bacalso Avenue, Cebu City
Tel # 261-7741 local 134
Website: http://www.cit.edu/

Name of Student: JUANITA A. DE LA CRUZ

Accreditation Level (if any): Year Granted:

Date School/Program was recognized: January 10, 2008 Number: 001 Year:
2008
First Course (if any): School Graduated From: Year:

Year of Admission in the Bachelor in Nursing Program:

Year Graduated (BSN Program):

I. MAJOR OPERATIONS

Date
Name of Signature
Performed Type of
Name of Operation Name of Name of O.R. of O.R.
No. and Case No. Diagnosis Anesthesi
Patient Performed Surgeon Hospital Scrub Scrub
Time a
Nurse Nurse
Started

Prepared by: ____JUANITA A. DE LA CRUZ_____

Signature over printed name of Student
Supervised by: Noted by: Concurred by: Approved by:

Mr. Sandro C. Villareal Mrs. Ailen C. Dungog Dr. Alma B. Ungab __

Dr. Judith D. Ismael
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse
Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :

Degree : BSN, RN, MAN Degree : BSN, RN, MN Degree : BSN, RN, MN, DPA
Degree : BSN, RN, MN, DODT
PRC No. : 0185185 PRC No. : 0281011 PRC No. : 0033433 PRC No.
: 0089124
Valid Until : January 12, 2013 Valid Until : May 27, 2011 Valid Until : December 28, 2011 Valid until
: September 22, 2011
CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY
COLLEGE OF NURSING
N. Bacalso Avenue, Cebu City
Tel # 261-7741 local 134
Website: http://www.cit.edu/

Name of Student: JUANITA A. DE LA CRUZ

Accreditation Level (if any): Year Granted:

Date School/Program was recognized: January 10, 2008 Number: 001 Year:
2008
First Course (if any): School Graduated From: Year:

Year of Admission in the Bachelor in Nursing Program:

Year Graduated (BSN Program):

II. MINOR OPERATIONS

No. Date Case No. Name of Diagnosis Operation Type of Name of Name of Name of Signature
Performed Patient Performed Anesthesi Surgeon Hospital O.R. of O.R.
 and
Scrub Scrub
Time a
Nurse Nurse
Started

Prepared by: ____JUANITA A. DE LA CRUZ_____

Signature over printed name of Student

Supervised by: Noted by: Concurred by: Approved by:

Mr. Sandro C. Villareal Mrs. Ailen C. Dungog Dr. Alma B. Ungab __

Dr. Judith D. Ismael
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse
Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :

Degree : BSN, RN, MAN Degree : BSN, RN, MN Degree : BSN, RN, MN, DPA
Degree : BSN, RN, MN, DODT
PRC No. : 0185185 PRC No. : 0281011 PRC No. : 0033433 PRC No.
: 0089124
Valid Until : January 12, 2013 Valid Until : May 27, 2011 Valid Until : December 28, 2011 Valid until
: September 22, 2011
CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY
COLLEGE OF NURSING
N. Bacalso Avenue, Cebu City
Tel # 261-7741 local 134
Website: http://www.cit.edu/

Name of Student: JUANITA A. DE LA CRUZ

Accreditation Level (if any): Year Granted:

Date School/Program was recognized: January 10, 2008 Number: 001 Year:
2008
First Course (if any): School Graduated From: Year:

Year of Admission in the Bachelor in Nursing Program:

Year Graduated (BSN Program):

III. ACTUAL DELIVERIES

Supervised
Date of Time of by:
Gender Type of Name of
No. Case No. Diagnosis Name of Patient Age Deliver Deliver Name &
of Baby Delivery Hospital
y y Signature of
Qualified CI

Prepared by: ____JUANITA A. DE LA CRUZ_____

Signature over printed name of Student

Supervised by: Noted by: Concurred by: Approved by:

Mr. Sandro C. Villareal Mrs. Ailen C. Dungog Dr. Alma B. Ungab __

Dr. Judith D. Ismael
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse
Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :

Degree : BSN, RN, MAN Degree : BSN, RN, MN Degree : BSN, RN, MN, DPA
Degree : BSN, RN, MN, DODT
PRC No. : 0185185 PRC No. : 0281011 PRC No. : 0033433 PRC No.
: 0089124
Valid Until : January 12, 2013 Valid Until : May 27, 2011 Valid Until : December 28, 2011 Valid until
: September 22, 2011
CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY
COLLEGE OF NURSING
N. Bacalso Avenue, Cebu City
Tel # 261-7741 local 134
Website: http://www.cit.edu/

Name of Student: JUANITA A. DE LA CRUZ

Accreditation Level (if any): Year Granted:

Date School/Program was recognized: January 10, 2008 Number: 001 Year:
2008
First Course (if any): School Graduated From: Year:

Year of Admission in the Bachelor in Nursing Program:

Year Graduated (BSN Program):

IV. DELIVERIES ASSISTED

Supervised
Date of Time of by:
Gender Type of Name of
No. Case No. Diagnosis Name of Patient Age Deliver Deliver Name &
of Baby Delivery Hospital
y y Signature of
Qualified CI
Prepared by: ____JUANITA A. DE LA CRUZ_____
Signature over printed name of Student

Supervised by: Noted by: Concurred by: Approved by:

Mr. Sandro C. Villareal Mrs. Ailen C. Dungog Dr. Alma B. Ungab __

Dr. Judith D. Ismael
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse
Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :

Degree : BSN, RN, MAN Degree : BSN, RN, MN Degree : BSN, RN, MN, DPA
Degree : BSN, RN, MN, DODT
PRC No. : 0185185 PRC No. : 0281011 PRC No. : 0033433 PRC No.
: 0089124
Valid Until : January 12, 2013 Valid Until : May 27, 2011 Valid Until : December 28, 2011 Valid until
: September 22, 2011
CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY
COLLEGE OF NURSING
N. Bacalso Avenue, Cebu City
Tel # 261-7741 local 134
Website: http://www.cit.edu/

Name of Student: JUANITA A. DE LA CRUZ

Accreditation Level (if any): Year Granted:

Date School/Program was recognized: January 10, 2008 Number: 001 Year:
2008
First Course (if any): School Graduated From: Year:

Year of Admission in the Bachelor in Nursing Program:

Year Graduated (BSN Program):

 V. CORD DRESSING

Date and Time Name of Supervised by:

of Delivery Hospital Name &
No. Case No. Name of Baby Gender of Baby Name of Mother Age
Signature of
Qualified CI

Prepared by: ____JUANITA A. DE LA CRUZ_____

Signature over printed name of Student

Supervised by: Noted by: Concurred by: Approved by:

Mr. Sandro C. Villareal Mrs. Ailen C. Dungog Dr. Alma B. Ungab __

Dr. Judith D. Ismael
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse
Signature over printed name of Dean
Date Signed : Date Signed : Date Signed : Date Signed :

Degree : BSN, RN, MAN Degree : BSN, RN, MN Degree : BSN, RN, MN, DPA
Degree : BSN, RN, MN, DODT
PRC No. : 0185185 PRC No. : 0281011 PRC No. : 0033433 PRC No.
: 0089124
Valid Until : January 12, 2013 Valid Until : May 27, 2011 Valid Until : December 28, 2011 Valid until
: September 22, 2011