POLYTECHNIC COLLEGE OF DAVAO DEL SUR

McArthur Highway, Digos City

Name of Student: Jericho Fuentesfina Deiparine_____

__________________________________________________________________________________________________________________
Name & Address of School: _ Polytechnic College of Davao del Sur, Inc., MacArthur Highway, Digos City _______________________________________________________________________________

Accreditation Level (if any): None__________________________________

Year Graduated: None______________________________________________________________
Date School/Program was Recognized: September 2____________________
Number: 28______________________________________
Year: 1994______________
First Course (if any): None________________________________________
School Graduated Form: None______________
Year: None______________
Year of Admission in Bachelor of Science in Nursing: 2006____________________________________________________________________________________________________________________ ___
Year Graduated in the BSN Program: 2010__________________________________________________________________________________________________________________________________ ___

No.

Date of
Operation

Case No.

Name of
Patient

Diagnosis

Operation
Performed

II. MINOR OPERATION

Type of
Name of
Anesthesia
Surgeon

Name of Hospital

Name of OR Scrub
Nurse

Signature of
OR Scrub
Nurse

Name and Signature of C.I.

.
FEBRUARY 18,
2009

1555947

A. M. T.

Corneal Opacity Secondary to Herpes

Zoster Ophthalmicus

FEBRUARY 25,
2009

2037312

J. A. T.

MAY 25, 2009

200955970
5

R. A. S.

Tarsorrhaphy,
Right Eye

Local
Anesthesia

Dr. Sigrid R. Calzada

Davao Medical
Center

Heide Y. Libumfacil,
RN
License No. 0140744

Corneal Foreign Body, Both Eyes

Removal of
Foreign Body

Local
Anesthesia

Dr. Shahid M.
Sinolinding

Davao Medical
Center

Heide Y. Libumfacil,
RN
License No. 0140744

Merilyn C. Rollo, RN
License No. 0126402

Mass Left Thigh

Excision of
Sebaceous Cyst

Local
Anesthesia

Dr. Josil R. Cruz

Davao Medical
Center

Ruby Mae T. Parantar,

RN
License No. 0332648

Merilyn C. Rollo, RN
License No. 0126402

Prepared By:
JERICHO FUENTESFINA DEIPARINE
Signature over printed name of Student
Noted By:

Concurred By:

Approved By:

MARINA LIO-LEDESMA, RN, MAN

Signature over printed name of Clinical Coordinator
Date Signed: ____________________________
Degree: ___BSN, MAN____________________
a.) PRC No.: 0089247_____________________
Valid Until: MARCH 3, 2013____________
b.) PNA No.: 4573_____________________ _ _
Valid Until: LIFETIME_MEMBER____ __

VILMA L. COMODA, RN, MAN

Signature over printed name of Chief Nurse
Date Signed: ________________________
Degree: ___BSN, MAN________________
a.) PRC No.: 0106605_________________
Valid Until: DECEMBER 23, 2012__ __
b.) PNA No.: 4569____________________
Valid Until: LIFETIME____________ _
c.) ANSAP No.: 5648______________ ___
Valid Until: LIFETIME______________

JENNIFER P. YBAEZ, RN, MAN

Signature over printed name of Dean
Date Signed: _________________________
Degree: ___BSN, MAN_________________
a.) PRC No.: 0367521__________________
Valid Until: JUNE 23, 2011___________
b.) PNA No.: _019672______
_____
Valid Until: OCTOBER 31, 2010_____ __
c.) ADPCN No.: 0772_____________ _____
Valid Until: DECEMBER 2010________

Merilyn C. Rollo, RN
License No. 0126402