COLLEGE OF THE HOLY SPIRIT OF TARLAC

COLLEGE OF NURSING

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
Name of Signature of
Date of Case Name of Operation Type of Name of Name of
No. Diagnosis O.R. Scrub O.R. Scrub
Operation No. Patient Performed Anesthesia Surgeon Hospital
Nurse Nurse

1.

2.

3.

4.

5.

Noted by:
b.) PNA NO: _____________________________ a.) PRC NO: _____________________________
_______________________________________ Valid Until: ___________________________ Valid Until: ___________________________
Signature over printed name of Chief Nurse b.) PNA NO: _____________________________
_______________________________________ Valid Until: ___________________________
Date Signed: ____________________________ Signature over printed name of Chief Nurse
Degree:_________________________________ _______________________________________
a.) PRC NO: ____________________________ Date Signed: ____________________________ Signature over printed name of Clinical Coordinator
Valid Until: ___________________________ Degree:_________________________________ _____________________________________
b.) PNA NO: _____________________________ a.) PRC NO: _____________________________ Date Signed: ____________________________ Signature over printed name of Dean
Valid Until: ___________________________ Valid Until: ___________________________ Degree:_________________________________
Date Signed: __________________________ Valid Until: _________________________ c.) ADPCN No: ________________________
Degree:______________________________ b.) PNA NO: __________________________ Valid Until: _________________________
a.) PRC NO: __________________________ Valid Until: _________________________