UNIVERSITY OF PANGASINAN COLLEGE OF NURSING DAGUPAN CITY

NAME OF STUDENT: Name and Address of School: SANTOS, Paul Christian Padama University of Pangasinan Arellano St., Dagupan City Accreditation Level (if any): Level I (PACUCOA) Year Granted: March 05, 2007 Date School / Program was recognized: May 19, 1976 Number: 44 Year: 1976 First Course (if any): School graduated from: Year: Year of admission in the BSN Program: June 2007 Year graduated from BSN Program: 2010 I. MAJOR OPERATIONS REMOVE “S” IF ONLY CONTAINS 1 CASE
No.
DATE of OPERATION TIME OF OPERATION STARTEDENDED NAME OF PATIENT CASE NO.

University Seal

DIAGNOSIS

OPERATION PERFORMED

TYPE of NAME of NAME of Name and Signature of Qualified ANESTHESIA SURGEON HOSPITAL Clinical Instructor Local, Regional, General, Intravenous Sedation
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1

Put 0 if 1-9 May 05
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1-9 Never Put 0 Just type 8:00 AM/PM
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No abbreviations

No abbreviations

Dr.

ALLCAPS HOSPITAL ACRONYM
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I-AM D. CI, RN

[PUT “MRS.” IF Female and Married]

2 3 4

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Remove if unfilled AND ENLARGE THE UPang LOGO [3-5 CASES logo size = 1Peso Coin] [1-2 CASES logo size = 5Peso Coin] and consume the SPACE
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Remove if unfilled Remove if unfilled 5 LEGEND: HOSPITAL’S ACRONYM = Hospital’s Complete Name (Level) [Bold Letters Here]

Prepared by: PAUL CHRISTIAN P. SANTOS Student

Concurred by: _____,Chief Nurse Date Signed: Degree: a). PRC No.: b). PNA No.: c). ANSAP No.: Valid Until: Valid Until: Valid Until:

Supervised by: Clinical Instructor Date Signed: Degree: a). PRC No.: b). PNA No.: Valid Until: Valid Until:

Noted by: ZENAIDA M. BAUTISTA Clinical Coordinator Date Signed: Degree: a). PRC No.: b). PNA No.: c). ANSAP No.: BSN-RN, MAN 0133422 Valid Until: July 27, 2011 029069 Valid Until: December 31, 2009 09-0054 Valid Until: December 31, 2009

Approved by: MELANIA C. CENON Dean Date Signed: Degree: a). PRC No.: b). PNA No.: c). ADPCN No.: BSN-RN, MAN, MAEd, PhD 0100236 Valid Until: January 06, 2012 17978 Valid Until: Lifetime Member 0185 Valid Until: December 31, 2009

RED INKS ARE THE GUIDES IN FILLING YOUR CASES DELETE IT BEFORE PRINTING

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