UNIVERSITY OF PANGASINAN COLLEGE OF NURSING

Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

I.
No. DATE of OPERATION TIME of OPERATION STARTEDENDED PATIENT¶S INITIALS DIAGNOSIS CASE NO.

MAJOR OPERATIONS
OPERATION PERFORMED TYPE of ANESTHESIA NAME of SURGEON NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

1 2 3 4 5 LEGEND:
Concurred by:

Prepared by:

Student

Chief Nurse PRC I.D. No.: Valid Until: Valid Until: PNA No.: ANSAP No.: Valid Until: Date document is signed: Please Specify Highest Nursing Degree Earned: Noted by: ZENAIDA M. BAUTISTA Clinical Coordinator Valid Until: July 27, 2011 PRC I.D. No.: 0133422 PNA No.: 029069 Valid Until: October 31, 2010 Time: Date document is signed: Please Specify Highest Nursing Degree Earned: M.A.N. Approved by:

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

MARIA TERESA R. FAJARDO Dean Valid Until: September 09, 2013 PRC I.D. No.: 0160104 PNA No.: 013739 Valid Until: October 31, 2010 Valid Until: ADPCN No.: Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING
Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

II.
No. DATE of OPERATION TIME of OPERATION STARTEDENDED PATIENT¶S INITIALS DIAGNOSIS CASE NO.

MINOR OPERATIONS
OPERATION PERFORMED TYPE of ANESTHESIA NAME of SURGEON NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

1 2 3 4 5 LEGEND:
Concurred by:

Prepared by:

Student

Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: Valid Until: ANSAP No.: Date document is signed: Please Specify Highest Nursing Degree Earned: Noted by: ZENAIDA M. BAUTISTA Clinical Coordinator Valid Until: July 27, 2011 PRC I.D. No.: 0133422 PNA No.: 029069 Valid Until: October 31, 2010 Time: Date document is signed: Please Specify Highest Nursing Degree Earned: M.A.N. Approved by:

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

MARIA TERESA R. FAJARDO Dean Valid Until: September 09, 2013 PRC I.D. No.: 0160104 PNA No.: 013739 Valid Until: October 31, 2010 Valid Until: ADPCN No.: Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING
Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

III.
No. 1 2 3 4 5 LEGEND: DIAGNOSIS MOTHER¶S INITIALS CASE NO. AGE DATE of DELIVERY

ACTUAL DELIVERIES
TIME of DELIVERY GENDER of BABY TYPE of DELIVERY NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

Concurred by:

Prepared by:

Student

Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: ANSAP No.: Valid Until: Date document is signed: Please Specify Highest Nursing Degree Earned:

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

Noted by:

ZENAIDA M. BAUTISTA Clinical Coordinator Valid Until: July 27, 2011 PRC I.D. No.: 0133422 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

Approved by:

MARIA TERESA R. FAJARDO Dean Valid Until: September 09, 2013 PRC I.D. No.: 0160104 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING
Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

IV.
No. 1 2 3 4 5 LEGEND: DIAGNOSIS MOTHER¶S INITIALS CASE NO. AGE DATE of DELIVERY

ASSISTED DELIVERIES
TIME of DELIVERY GENDER of BABY TYPE of DELIVERY NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

Concurred by:

Prepared by:

Student

Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: Valid Until: ANSAP No.: Date document is signed: Please Specify Highest Nursing Degree Earned:

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

Noted by:

ZENAIDA M. BAUTISTA Clinical Coordinator Valid Until: July 27, 2011 PRC I.D. No.: 0133422 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

Approved by:

MARIA TERESA R. FAJARDO Dean Valid Until: September 09, 2013 PRC I.D. No.: 0160104 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING
Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

V.
No. 1 2 3 4 5 LEGEND: DATE PERFORMED TIME OF DELIVERY

IMMEDIATE NEWBORN CORD CARE
GENDER of BABY MOTHER¶S INITIALS AGE NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

BABY¶S INITIALS CASE NO.

Concurred by:

Prepared by:

Student

Chief Nurse Valid Until: PRC I.D. No.: PNA No.: Valid Until: ANSAP No.: Valid Until: Date document is signed: Please Specify Highest Nursing Degree Earned:

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

Noted by:

ZENAIDA M. BAUTISTA Clinical Coordinator Valid Until: July 27, 2011 PRC I.D. No.: 0133422 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

Approved by:

MARIA TERESA R. FAJARDO Dean Valid Until: September 09, 2013 PRC I.D. No.: 0160104 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please Specify Highest Nursing Degree Earned: M.A.N.

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