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Old Prc Form for 3bu

Old Prc Form for 3bu

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Published by Aaron Jay
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Published by: Aaron Jay on Jan 26, 2011
Copyright:Attribution Non-commercial

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04/15/2011

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Name of Student:____________________________________________________________________________________________________________________________________________________________ Name & Address of School:Accreditation Level: (if any) None Year Granted NoneDate School/Program was Recognized: April 11, 2003 Number (
GR
) 07 Year 2003First 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 OPERATIONSNo.Date oOperationCase No.Name oPatientDiagnosisOperationPerformedType of AnesthesiaName of SurgeonName of HospitalName and Signature of O.R. ScrubNurseSupervised by
1
Mr. Maria dela Cruz, RN, MAN
Date Signed: Degree: _______________ a) PRC No:___________ Valid Until: __________b) PNA No.:________Valid Until: ______________ 23
St. Scholastica’s College TaclobanCollege of Nursing & Midwifery
Manlurip, San Jose, Tacloban CityTel.No. (053) 325-2188 local 201
 
45
NOTED BY: CONCURRED BY:
 __________________________________ 
Signature over Printed Name of Clinical Coordinator SSCHS, College of NursingDate signed:______________________________ Degree: _____________________ a)PRC No.: ______________________Valid Until: ______________ b)PNA 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 theprovisions of pertinent laws, rules and regulations of the Republic of the Philippines.
 ____________________________________ 
Signature over Printed Name of Chief Nurse
Divine Word HospitalDate signed:___________________________________ Degree: ______________________ a)PRC No.: __________________________ Valid Until: _____________________ b)PNA No.: ____________________________ Valid Until: ________________________ 
 ______________________________________ 
Signature over Printed Name of DeanSSCHS, College of NursingDatesigned:_____________________________________ Degree: _____________________ a)PRC No.: ____________________________ Valid Until: _________________________ b)PNA No.: ______________________________ Valid Until: ________________________ c)ADPCN No.: ________________________________ Valid Until: _______________________ 
C
 
ONCURRED BY:
 _________________________________________ 
Signature over Printed Name of Chief NurseEastern Visayas Regional Medical Center Date signed:________________________________________ Degree: ____________________________ a)PRC No.: ________________________________ Valid Until: __________________________ b)PNA No.: ___________________________________ Valid Until: ___________________________
APPROVED BY:
 
Subscribed and sworn before me this _____ day of ___________ 20______, Philippines. _________________________________ Signature of ApplicantDoc. No. _________________ Page No. _________________ Book No. _________________ Series of: _________________  Name of Student: _______________________________________________________________________________________________________________________________ Name & Address of School:Accreditation Level: (if any) None Year Granted NoneDate School/Program was Recognized: April 11, 2003 Number (
GR
) 07 Year 2003First 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 CruzSignature over printed name
II. MINOR OPERATIONSNo.Date oOperationCase No.Name oPatientDiagnosisOperationPerformedType of AnesthesiaName of SurgeonName of HospitalName of Nurse onDutySupervised by
12
St. Scholastica’s College TaclobanCollege of Nursing & Midwifery
Manlurip, San Jose, Tacloban CityTel.No. (053) 325-2188 local 201

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