ST. SCHOLASTICAS COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy.

87, Manlurip, San Jose, Tacloban City ASSISSTED DELIVERY in EASTERN VISAYAS REGIONAL MEDICAL CENTER, TACLOBAN CITY LEYTE Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student: Date Performed and Time Started Patients INITIALS Case Number Midwife/Nurse on Duty (Nurse and Signature)

ASSISTED DELIVERY FORM

SUPERVISED BY Clinical Instructor (Name and Signature)

PROCEDURE PERFORMED

SR. AMPARO A. SALENTES OSB, RN, MAN Over-all Clinical Coordinator PRC No.: Valid until: PNA No.: Valid until:

MRS. CAROLINA D. BARROT, RN, MAN, PhD DEAN PRC No.: Valid until: PNA No.: Valid until: ADPCN: Valid until: 133674 September 21, 2014

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, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn to before me this day of , 2013, Tacloban City, Philippines. Doc No. Page No. Book No. Series of 2013

ST. SCHOLASTICAS COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City CORD CARE in EASTERN VISAYAS REGIONAL MEDICAL CENTER, TACLOBAN CITY LEYTE Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student: Date Performed and Time Started Patients INITIALS Case Number IMMEDIATE NEWBRN CORD CARE PERFORMED Midwife/Nurse on Duty (Nurse and Signature)

IMMEDIATE NEWBORN CORD CARE FORM

SUPERVISED BY Clinical Instructor (Name and Signature)

SR. AMPARO A. SALENTES OSB, RN, MAN Over-all Clinical Coordinator PRC No.: Valid until: PNA No.: Valid until:

MRS. CAROLINA D. BARROT, RN, MAN, PhD DEAN PRC No.: Valid until: PNA No.: Valid until: ADPCN: Valid until: 133674 September 21, 2014

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, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn to before me this day of , 2013, Tacloban City, Philippines. Doc No. Page No. Book No. Series of 2013

ST. SCHOLASTICAS COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City SURGICAL SCRUB in EASTERN VISAYAS REGIONAL MEDICAL CENTER, TACLOBAN CITY LEYTE Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student: Date Performed and Time Started Patients INITIALS Case Number O.R. Nurse on Duty (Nurse and Signature)

O.R. Form 1A MAJOR SURGERY

SUPERVISED BY Clinical Instructor (Name and Signature)

SURGICAL PROCEDURE PERFORMED

SR. AMPARO A. SALENTES OSB, RN, MAN Over-all Clinical Coordinator PRC No.: Valid until: PNA No.: Valid until:

MRS. CAROLINA D. BARROT, RN, MAN, PhD DEAN PRC No.: Valid until: PNA No.: Valid until: ADPCN: Valid until: 133674 September 21, 2014

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, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn to before me this day of , 2013, Tacloban City, Philippines. Doc No. Page No. Book No. Series of 2013

ST. SCHOLASTICAS COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City CIRCULATING NURSE in EASTERN VISAYAS REGIONAL MEDICAL CENTER, TACLOBAN CITY LEYTE Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student: Date Performed and Time Started Patients INITIALS Case Number O.R. Nurse on Duty (Nurse and Signature)

O.R. Form 1A MAJOR SURGERY

SUPERVISED BY Clinical Instructor (Name and Signature)

SURGICAL PROCEDURE PERFORMED

SR. AMPARO A. SALENTES OSB, RN, MAN Over-all Clinical Coordinator PRC No.: Valid until: PNA No.: Valid until:

MRS. CAROLINA D. BARROT, RN, MAN, PhD DEAN PRC No.: Valid until: PNA No.: Valid until: ADPCN: Valid until: 133674 September 21, 2014

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, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn to before me this day of , 2013, Tacloban City, Philippines. Doc No. Page No. Book No. Series of 2013

ST. SCHOLASTICAS COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City SURGICAL SCRUB in DIVINE WORD HOSPITAL, TACLOBAN CITY, LEYTE Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student: Date Performed and Time Started Patients INITIALS Case Number O.R. Nurse on Duty (Nurse and Signature)

O.R. Form 1A MAJOR SURGERY

SUPERVISED BY Clinical Instructor (Name and Signature)

SURGICAL PROCEDURE PERFORMED

SR. AMPARO A. SALENTES OSB, RN, MAN Over-all Clinical Coordinator PRC No.: Valid until: PNA No.: Valid until:

MRS. CAROLINA D. BARROT, RN, MAN, PhD DEAN PRC No.: Valid until: PNA No.: Valid until: ADPCN: Valid until: 133674 September 21, 2014

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, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn to before me this day of , 2013, Tacloban City, Philippines. Doc No. Page No. Book No. Series of 2013

ST. SCHOLASTICAS COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City CIRCULATING NURSE in DIVINE WORD HOSPITAL, TACLOBAN CITY, LEYTE Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student: Date Performed and Time Started Patients INITIALS Case Number O.R. Nurse on Duty (Nurse and Signature)

O.R. Form 1A MAJOR SURGERY

SUPERVISED BY Clinical Instructor (Name and Signature)

SURGICAL PROCEDURE PERFORMED

SR. AMPARO A. SALENTES OSB, RN, MAN Over-all Clinical Coordinator PRC No.: Valid until: PNA No.: Valid until:

MRS. CAROLINA D. BARROT, RN, MAN, PhD DEAN PRC No.: Valid until: PNA No.: Valid until: ADPCN: Valid until: 133674 September 21, 2014

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, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn to before me this day of , 2013, Tacloban City, Philippines. Doc No. Page No. Book No. Series of 2013