REPUBLIC OF THE PHILIPPINES

PROFESSIONAL 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
Operation

Case
No.

Name of Patient

Diagnosis

Operation
Performed

Type of
Anesthesia

Name of
Surgeon

Name of
Hospital

Name of O.R.
Scrub Nurse

Signature of
O.R. Scrub
Nurse

1.
2.
3.
4.
5.
Noted by:
_______________________________________
Signature over printed name of Chief
Nurse
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: ___________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________

_______________________________________
Signature over printed name of Chief
Nurse
Date 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 Dean
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________
c.) ADPCN NO:___________________________
Valid Until: ___________________________

REPUBLIC OF THE PHILIPPINES

PROFESSIONAL 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):____________________________________________________________________________________________
II. Minor Operations
No.

Date of
Operation

Case No.

Name of Patient

Diagnosis

Operation
Performed

Type of
Anesthesia

Name of Surgeon

Name of Hospital

Name of O.R.
Scrub Nurse

Signature of
O.R. Scrub
Nurse

1.
2.
3.
4.
5.
Noted by:
_______________________________________
Signature over printed name of Chief
Nurse
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________

_______________________________________
Signature over printed name of Chief
Nurse
Date 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 Dean
Date Signed: ____________________________
Degree:_________________________________
b.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________
c.) ADPCN NO:___________________________
Valid Until: ___________________________

REPUBLIC OF THE PHILIPPINES

PROFESSIONAL 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):____________________________________________________________________________________________
III. Actual Deliveries
No.

Case
No.

Diagnosis

Name of
Mother

Age

Date of
Delivery

Time of
Delivery

Gender
of
Baby

Name of
Hospital

Type of Delivery

Supervised by:
Signature of OR/DR
Supervisor

1.
2.
3.
4.
5.
Noted by:
_______________________________________
Signature over printed name of Chief
Nurse
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________

_______________________________________
Signature over printed name of Chief
Nurse
Date 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 Dean
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________
c.) ADPCN NO:___________________________
Valid Until: ___________________________

REPUBLIC OF THE PHILIPPINES

PROFESSIONAL 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):____________________________________________________________________________________________
IV. Deliveries Assisted
No.

Case No.

Diagnosis

Name of
Mother

Age

Date of
Delivery

Time of
Delivery

Gender of
Baby

Name of Hospital

Type of Delivery

Supervised by:
Signature of
Qualified C.I.

1.
2.
3.
4.
5.
Noted by:
_______________________________________
Signature over printed name of Chief
Nurse
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________

_______________________________________
Signature over printed name of Chief
Nurse
Date 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: ______________________________
Valid Until: __________________________

______________________________________
Signature over printed name of Dean
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________
c.) ADPCN NO:___________________________
Valid Until: ___________________________

REPUBLIC OF THE PHILIPPINES

PROFESSIONAL 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):____________________________________________________________________________________________
V. Cord Dressing
No.

Case No.

Date
Performed

Name of Baby

Gender of
Baby

Name of Mother

Age

Name of Hospital

Supervised by: Signature of

Qualified C.I.

1.

2.

3.

4.

5.

Noted by:
_______________________________________
Signature over printed name of Chief
Nurse
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________

_______________________________________
Signature over printed name of Chief
Nurse
Date 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 Dean
Date Signed: ____________________________
Degree:_________________________________
a.) PRC NO: ____________________________
Valid Until: __________________________
b.) PNA NO: _____________________________
Valid Until: ___________________________
c.) ADPCN NO:___________________________

Valid Until: