University of Regina Carmeli

Malolos City, Bulacan

Name and address of school :

Name of Student :
_________
Accreditation Level : Date Granted :
Date School / Program was Recognized : Number : Year :

First Course (if any) : None

___________________
Year of Admission in the Bachelor of Science in Nursing Program :

Year Graduate (BSN Program) :

I. MAJOR OPERATIONS
Date of Supervised by
No Name of Type of
Operatio Case No. Diagnosis Operation Performed Name of Surgeon Name of Hospital (Name & Signature of Qualified Clinical
. Patient Anesthesia
n Instructor)

Signature over printed Name w/Degree of

CI/Date singed
1 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
2 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
3 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
4 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
5 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________
Noted by: Concurred by: Approved by:
 ________________________________
Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed Name
of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: Degree: Degree: Degree:

a.) PRC No.: a.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid until: Valid until:

b.) PNA No.: b.) PNA No.: b.) PNA No.: b.) PNA No.:
Valid until: Valid until: Valid until: Valid until:
c.) ADPCN
No.: Valid until:

Prepared by:__________________________________

University of Regina Carmeli

Malolos City, Bulacan

Name and address of school :

Name of Student :
_________
Accreditation Level : Date Granted :
Date School / Program was Recognized : Number : Year :

First Course (if any) : None

___________________
Year of Admission in the Bachelor of Science in Nursing Program :

II. MINOR OPERATIONS

Date of Supervised by
No Name of Type of
Operatio Case No. Diagnosis Operation Performed Name of Surgeon Name of Hospital (Name & Signature of Qualified Clinical
. Patient Anesthesia
n Instructor)

Signature over printed Name w/Degree of

CI/Date singed
1 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________
 Signature over printed Name w/Degree of
CI/Date singed
2 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
3 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
4 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Signature over printed Name w/Degree of

CI/Date singed
5 PRC No. _______________Valid
Untill________________
PNA No.:_______________ Valid
until:______________

Noted by: Concurred by: Approved by:

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed Name
of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: Degree: Degree: Degree:

a.) PRC No.: a.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid until: Valid until:

b.) PNA No.: b.) PNA No.: b.) PNA No.: b.) PNA No.:
Valid until: Valid until: Valid until: Valid until:
c.) ADPCN
No.: Valid until:

Prepared by:__________________________________
 University of Regina Carmeli
Malolos City, Bulacan

Name and address of school :

Name of Student :
_________
Accreditation Level : Date Granted :
Date School / Program was Recognized : Number : Year :

First Course (if any) : None

___________________
Year of Admission in the Bachelor of Science in Nursing Program :

Year Graduate (BSN Program) :

III. ACTUAL DELIVERIES

Supervised by
No Case Date of Time of Gender of
Diagnosis Name of Mother Age Name of Hospital Type of Delivery (Name & Signature of Qualified Clinical
. No. Delivery Delivery Baby
Instructor)

Signature over printed Name w/Degree

of CI/Date singed
1 PRC No. ___________Valid
Untill________________
PNA No.:______________Valid
until:______________

Signature over printed Name w/Degree

of CI/Date singed
2 PRC No. ___________Valid
Untill________________
PNA No.:______________Valid
until:______________

Signature over printed Name w/Degree

of CI/Date singed
3 PRC No. ___________Valid
Untill________________
PNA No.:______________Valid
until:______________

Signature over printed Name w/Degree

of CI/Date singed
4 PRC No. ___________Valid
Untill________________
PNA No.:______________Valid
until:______________

Signature over printed Name w/Degree

of CI/Date singed
5 PRC No. ___________Valid
Untill________________
PNA No.:______________Valid
until:______________

Noted by: Concurred by: Approved by:

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed Name
of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: Degree: Degree: Degree:

a.) PRC No.: a.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid until: Valid until: _

b.) PNA No.: b.) PNA No.: b.) PNA No.: b.) PNA No.:
Valid until: Valid until: Valid until: Valid until:
c.) ADPCN
No.: Valid until:

Prepared by:__________________________________
 University of Regina Carmeli
Malolos City, Bulacan

Name and address of school :

Name of Student :
_________
Accreditation Level : Date Granted :
Date School / Program was Recognized : Number : Year :

First Course (if any) : None

___________________
Year of Admission in the Bachelor of Science in Nursing Program :

Year Graduate (BSN Program) :

IV. DELIVERIES ASSISTED

Supervised by
Date of Time of Gender of
No. Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery (Name & Signature of
Delivery Delivery Baby
Qualified Clinical Instructor)

Signature over printed Name

w/Degree of CI/Date singed
1 PRC No. _________Valid
Untill_______
PNA No.:________Valid
until:_________

Signature over printed Name

w/Degree of CI/Date singed
2 PRC No. _________Valid
Untill_______
PNA No.:________Valid
until:_________

Signature over printed Name

w/Degree of CI/Date singed
3 PRC No. _________Valid
Untill_______
PNA No.:________Valid
until:_________

Signature over printed Name

w/Degree of CI/Date singed
4 PRC No. _________Valid
Untill_______
PNA No.:________Valid
until:_________

Signature over printed Name

w/Degree of CI/Date singed
5 PRC No. _________Valid
Untill_______
PNA No.:________Valid
until:_________
Noted by: Concurred by: Approved by:
Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed Name
of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: Degree: Degree: Degree:

a.) PRC No.: a.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid until: Valid until: _

b.) PNA No.: b.) PNA No.: b.) PNA No.: b.) PNA No.:
Valid until: Valid until: Valid until: Valid until:
c.) ADPCN
No.: Valid until:

Prepared by:______________________________
University of Regina Carmeli
Malolos City, Bulacan

Name and address of school :

Name of Student :
_________
Accreditation Level : Date Granted :
Date School / Program was Recognized : Number : Year :

First Course (if any) : None

___________________
Year of Admission in the Bachelor of Science in Nursing Program :

Year Graduate (BSN Program) :

V. CORD DRESSING
Supervised by
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital (Name & Signature of Qualified
Clinical Instructor)

Signature over printed Name

w/Degree of CI/Date singed
1 PRC No. __________Valid
Untill__________
PNA No.:__________Valid
until:__________

Signature over printed Name

w/Degree of CI/Date singed
2 PRC No. __________Valid
Untill__________
PNA No.:__________Valid
until:__________
 Signature over printed Name
w/Degree of CI/Date singed
3 PRC No. __________Valid
Untill__________
PNA No.:__________Valid
until:__________

Signature over printed Name

w/Degree of CI/Date singed
4 PRC No. __________Valid
Untill__________
PNA No.:__________Valid
until:__________

Signature over printed Name

w/Degree of CI/Date singed
5 PRC No. __________Valid
Untill__________
PNA No.:__________Valid
until:__________
Noted by: Concurred by: Approved by:

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed Name
of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: Degree: Degree: Degree:

a.) PRC No.: a.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid until: Valid until:

b.) PNA No.: b.) PNA No.: b.) PNA No.: b.) PNA No.:
Valid until: Valid until: Valid until: Valid until:
c.) ADPCN
No.: Valid until:

Prepared by:____________________________