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REPUBLIC OF THE PHILIPPINESPROFESSIONAL REGULATION COMMISSION

Manila

Name of Student: ________________________________________________________________________________________________________ Name and Address of School: ______________________________________________________________________________________________ Accreditation Level (if any): _____________________________________Year Granted: ________________________________________________ Date School/Program was Recognized: ___________________________Number: ____________________________Year:_____________________ First Course (if any) :______________________________School Graduated From: ___________________________ Year_____________________ Year of Admission in the Bachelor of Science in Nursing Program: _________________________________________________________________ Year Graduated (BSN Program):____________________________________________________________________________________________

I. Major Operations

No.Date of OperationCaseNo.Name of PatientDiagnosisOperationPerformedType of AnesthesiaName of SurgeonName of HospitalName of O.R.Scrub NurseSignature of O.R. ScrubNurse1.2.3.4.5.Noted by: _______________________________________ Signature over printed name of Chief NurseDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: ___________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ _______________________________________ Signature over printed name of Chief NurseDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ _______________________________________ Signature over printed name of Clinical Coordinator Date Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: ___________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ ______________________________________ Signature over printed name of DeanDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ c.) ADPCN NO:___________________________ Valid Until: ____________________________

REPUBLIC OF THE PHILIPPINESPROFESSIONAL REGULATION COMMISSIONManila

II. Minor Operations

No.Date of OperationCase No.Name of PatientDiagnosisOperationPerformedType of AnesthesiaName of SurgeonName of HospitalName of O.R.Scrub NurseSignature of O.R. ScrubNurse1.2.3.4.5.Noted by: _______________________________________ Signature over printed name of Chief NurseDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ _______________________________________ Signature over printed name of Chief NurseDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ _______________________________________ Signature over printed name of Clinical Coordinator Date Signed: ____________________________ Degree:_________________________________ a.)PRC NO: _______________________________ Valid Until: ___________________________ Valid Until: ___________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ ______________________________________ Signature over printed name of DeanDate Signed: ____________________________ Degree:_________________________________ b.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ c.) ADPCN NO:___________________________ Valid Until: ____________________________

REPUBLIC OF THE PHILIPPINESPROFESSIONAL REGULATION COMMISSIONManila

III. Actual Deliveries

No.CaseNo.DiagnosisName of Mother AgeDate of DeliveryTime of DeliveryGender of BabyName of HospitalType of DeliverySupervised by:Signature of OR/DRSupervisor 1.2.3.4.5.Noted by: _______________________________________ Signature over printed name of Chief NurseDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ _______________________________________ Signature over printed name of Chief NurseDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ _______________________________________ Signature over printed name of Clinical Coordinator Date Signed: ____________________________ Degree:_________________________________ a.)PRC NO: _______________________________ Valid Until: ___________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________ ______________________________________ Signature over printed name of DeanDate Signed: ____________________________ Degree:_________________________________ a.)PRC NO: ____________________________ Valid Until: __________________________ b.) PNA NO: _____________________________ Valid Until: ___________________________

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Upload Date:	02/04/2010
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