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):_________________________________________________________________________________________________________________________________

III. Actual Deliveries

Name of Date of Time of Gender Name of Supervised by: Signature
No. Case No. Diagnosis Age Type of Delivery
Mother Delivery Delivery of Baby Hospital of OR/DR Supervisor

1.

2.

3.

Noted By:

_______________________________________ a.) PRC NO: _____________________________

Signature over printed name of Chief Nurse Valid Until: ___________________________ __________________________________
b.) PNA NO: _____________________________ Signature over printed name of Dean
Date Signed: ____________________________ Valid Until: ___________________________
Degree:_________________________________ Date Signed: _______________________
a.) PRC NO: ____________________________ Degree:___________________________
Valid Until: ___________________________ _______________________________________ a.) PRC NO: ________________________
b.) PNA NO: _____________________________ Signature over printed name of Clinical Coordinator Valid Until: ______________________
Valid Until: ___________________________ b.) PNA NO: ________________________
Date Signed: ____________________________ Valid Until: ______________________
Degree:_________________________________ c.) ADPCN NO: _____________________
_______________________________________ a.) PRC NO: _____________________________ Valid Until:
Signature over printed name of Chief Nurse Valid Until: ___________________________
b.) PNA NO: _____________________________
Date Signed: ____________________________ Valid Until: ___________________________
Degree:_________________________________