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BULACAN STATE UNIVERSITY

GUINHAWA, CITY OF MALOLOS, BULACAN

NAME OF STUDENT: First Course: NA
Name of School: Bulacan State University School Graduated: NA
Address of School: Guinhawa, City of Malolos, Bulacan Year of Admission in the BSN Program: 2007
Recognition and Accreditation Level: Year Graduated from the BSN Program:
Date When School was Recognized: December 4, 2003 Board Resolution

MAJOR OPERATIONS
Date of Case Name of Type of Name of the Name of OR Supervised by:
No. Diagnosis Operation Performed Anesthesia Name of Surgeon
Operation No. Patient Hospital Scrub Nurse (Name and Signature of qualified CI)

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Clinical Coordinator
.
(Chief Nurse – Bulacan Medical Center) (Clinical Coordinator) (Dean)
(Chief Nurse – Sacred Heart Hospital of Malolos Inc.)
Chief Nurse

Dean
Degree: Degree: Degree:
Degree:
Date Signed: __________________________ Date Signed: __________________________ Date Signed: __________________________
Date Signed: __________________________
PRC No.: Valid Until: PRC No.: Valid Until: PRC No.: Valid Until:
PRC No.: Valid Until:
PNA No.: Valid Until: PNA No.: Valid Until: PNA No.: Valid Until:
PNA No.: Valid Until:
ADPCN No.: Valid Until:

Notarized By:

: _ Valid Until: PRC No.: Valid Until: PNA No. Patient Anesthesia Hospital (Name and Signature of qualified CI) 1 2 3 4 5 CoordinatorClinical (Chief Nurse – Bulacan Medical Center) (Chief Nurse – Sacred Heart Hospital) (Dean) (Clinical Coordinator) Chief Nurse Dean Degree: Degree: Degree: Degree: Date Signed: __________________________ Date Signed: __________________________ Date Signed: __________________________ Date Signed: __________________________ PRC No. CITY OF MALOLOS. Operation No.: Valid Until: PRC No. BULACAN STATE UNIVERSITY GUINHAWA. City of Malolos.: Valid Until: PNA No.: Valid Until: Notarized By: .: Valid Until: ADPCN No. BULACAN NAME OF STUDENT: First Course: NA Name of School: Bulacan State University School Graduated: NA Address of School: Guinhawa.: Valid Until: PNA No.: Valid Until: PNA No.: Valid Until: PRC No. 2003 Board Resolution MINOR OPERATIONS No Date of Case Name of Type of Name of the Supervised by: Diagnosis Operation Performed Name of Surgeon . Bulacan Year of Admission in the BSN Program: 2007 Recognition and Accreditation Level: Year Graduated from the BSN Program: Date When School was Recognized: December 4.

: Valid Until: PNA No. Diagnosis Name of Mother Age Type of Delivery No. CITY OF MALOLOS. City of Malolos.: Valid Until: Notarized By: . Delivery Delivery of Baby Hospital (Name and Signature of qualified CI) 1 2 3 4 Clinical Coordinator (Chief Nurse – Bulacan Medical Center) (Clinical Coordinator) (Dean) Chief Nurse Degree: Dean Degree: Degree: Date Signed: __________________________ Date Signed: __________________________ Date Signed: __________________________ PRC No. BULACAN NAME OF STUDENT: First Course: NA Name of School: Bulacan State University School Graduated: NA Address of School: Guinhawa. BULACAN STATE UNIVERSITY GUINHAWA. Bulacan Year of Admission in the BSN Program: 2007 Recognition and Accreditation Level: Year Graduated from the BSN Program: Date When School was Recognized: December 4.: Valid Until: PRC No.: Valid Until: ADPCN No.: Valid Until: PNA No. 2003 Board Resolution ACTUAL DELIVERIES Case Date of Time of Gender Name of the Supervised by: No.: Valid Until: PRC No.: Valid Until: PNA No.

: Valid Until: PRC No. 2003 Board Resolution DELIVERIES ASSISTED Case Time of Gender Name of the Supervised by: No.: Valid Until: PNA No. Diagnosis Name of Mother Age Date of Delivery Type of Delivery No.: Valid Until: ADPCN No. BULACAN NAME OF STUDENT: First Course: NA Name of School: Bulacan State University School Graduated: NA Address of School: Guinhawa. City of Malolos.: Valid Until: PNA No. Degree: Date Signed: __________________________ Date Signed: __________________________ Date Signed: __________________________ PRC No. Delivery of Baby Hospital (Name and Signature of qualified CI) 1 2 3 4 5 Clinical Coordinator (Chief Nurse – Bulacan Medical Center) (Clinical Coordinator) (Dean) Chief Nurse Degree: Dean Degree:.: Valid Until: PRC No. Bulacan Year of Admission in the BSN Program: 2007 Recognition and Accreditation Level: Year Graduated from the BSN Program: Date When School was Recognized: December 4. CITY OF MALOLOS.: Valid Until: PNA No. BULACAN STATE UNIVERSITY GUINHAWA.: Valid Until: Notarized By: .

: Valid Until: PNA No.: Valid Until: Notarized By: .: Valid Until: PRC No. Bulacan Year of Admission in the BSN Program: 2005 Recognition and Accreditation Level: Year Graduated from the BSN Program: Date When School was Recognized: December 4.: Valid Until: PRC No.: Valid Until: PNA No.: Valid Until: ADPCN No. Case Number Date Performed Name of Baby Gender of Baby Name of Mother Age Name of the Hospital (Name and Signature of qualified CI) 1 2 3 4 5 Clinical Coordinator (Chief Nurse – Bulacan Medical Center) (Dean) (Clinical Coordinator) Chief Nurse Dean Degree: Degree: Degree: Date Signed: __________________________ Date Signed: __________________________ Date Signed: __________________________ PRC No. City of Malolos. BULACAN NAME OF STUDENT: First Course: NA Name of School: Bulacan State University School Graduated: NA Address of School: Guinhawa. 2003 Board Resolution CORD DRESSINGS Supervised by: No. CITY OF MALOLOS. BULACAN STATE UNIVERSITY GUINHAWA.: Valid Until: PNA No.