UNIVERSITY OF PANGASINAN

COLLEGE OF NURSING
Arellano St., Dagupan City University Seal
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: CORPUZ, Rezi Aquino First course (if any):

School graduated from:
Year:
Year of admission in the BSN Program: June 2008
Year graduated from BSN Program: 2011

II. MINOR OPERATION

TIME of PATIENT’S
DATE of OPERATION INITIALS OPERATION TYPE of NAME of NAME of
No. DIAGNOSIS Name & Signature of Qualified Clinical Instructor
OPERATION STARTED- PERFORMED ANESTHESIA SURGEON HOSPITAL
ENDED CASE NO.
Punctured wound
R.A.B.
February 06, 8:03 PM – Foreign Body Dr. Saniata
1 right foot retained local CDVMH Jommel F. Versola, RN
2011 8:17 PM 53699 Removal V. Fernandez
pieces of wood
LEGEND: CDVMH = Col. Domingo A. Valdez Memorial Hospital (Primary)

Concurred by: NIDA G. QUILON

Prepared by: CDVMH, Chief Nurse
PRC I.D. No.: 01197801 Valid Until: March 17, 2011
REZI A. CORPUZ PNA No.: 13609 Valid Until: Lifetime member
Student ANSAP No.: 090046 Valid Until: December 31. 2011
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: BSN RN MPH 27 units

Supervised by: JOMMEL F. VERSOLA Noted by: ZENAIDA M. BAUTISTA Approved by: MARIA TERESA R. FAJARDO
Clinical Instructor Clinical Coordinator Dean
Date signed: PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: 0160104 Valid Until: September 9, 2013
Degree: BSN RN PNA No.: 040412 Valid Until: October 31, 2011 PNA No.: 040351 Valid Until: October 31, 2011
PRC I.D. No.: 0400856 Valid Until: May 19, 2012 Date document is signed: Time: ADPCN No.: 19482 Valid Until: May 2011
PNA No.: 040447 Valid Until: October 31, 2011 Please specify Highest Nursing Degree Earned: MAN Date document is signed: Time:
Please specify Highest Nursing Degree Earned: MAN
 UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City University Seal
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)
First course (if any):
NAME OF STUDENT: CORPUZ, Rezi Aquino School graduated from:
Year:
Year of admission in the BSN Program: June 2008
Year graduated from BSN Program: 2011

III. ACTUAL DELIVERY

MOTHER’S
DATE of TIME of GENDER of TYPE NAME of
No. DIAGNOSIS INITIALS AGE Name & Signature of Qualified Clinical Instructor
DELIVERY DELIVERY BABY of DELIVERY HOSPITAL
CASE NO.
Pregnancy M.P.A. November 22, Normal Spontaneous
1 Uterine Full 27 08:40 AM Female WPDH Amelita D. Dumaguin, RN
187110 2010 Delvery
Term
LEGEND: WPDH = Western Pangasinan District Hospital (Secondary)

Concurred by: MA. CONCEPCION H. MIRANDA

Prepared by: WPDH, Chief Nurse
REZI A. CORPUZ PRC I.D. No.: 068019 Valid Until: March 26, 2011
Student PNA No.: 10441 Valid Until: Lifetime Member
ANSAP No.: 0384 Valid Until: Lifetime Member
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: M.AN.

Supervised by: AMELITA D. DUMAGUIN Noted by: ZENAIDA M. BAUTISTA Approved by: MARIA TERESA R. FAJARDO
Clinical Instructor Clinical Coordinator Dean
Date signed: PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: 0160104 Valid Until: September 9, 2013
Degree: BSN, RN PNA No.: 040412 Valid Until: October 31, 2011 PNA No.: 040351 Valid Until: October 31, 2011
PRC I.D. No.: 0243044 Valid Until: December 15, 2012 Date document is signed: Time: ADPCN No.: 19482 Valid Until: May 2011
PNA No.: 040322 Valid Until: December 31, 2011 Please specify Highest Nursing Degree Earned: MAN Date document is signed: Time:
Please specify Highest Nursing Degree Earned: MAN
 UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City University Seal
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)
First course (if any):
NAME OF STUDENT: CORPUZ, Rezi Aquino School graduated from:
Year:
Year of admission in the BSN Program: June 2008
Year graduated from BSN Program: 2011

IV. ASSISTED DELIVERY

MOTHER’S
DATE of TIME of GENDER of TYPE NAME of
No. DIAGNOSIS INITIALS AGE Name & Signature of Qualified Clinical Instructor
DELIVERY DELIVERY BABY of DELIVERY HOSPITAL
CASE NO.
Pregnancy Uterine
R.Y.R.
40 weeks Age of November 23, Normal Spontaneous
1 26 10:55 AM female WPDH
Gestation, Gravida 2010 Delivery Amelita D. Dumaguin, RN
187144
4, Para 4
LEGEND: WPDH = Western Pangasinan District Hospital (Secondary)

Prepared by:
REZI A. CORPUZ Concurred by: MA. CONCEPCION H. MIRANDA
Student WPDH, Chief Nurse
PRC I.D. No.: 068019 Valid Until: March 26, 2011
PNA No.: 10441 Valid Until: Lifetime Member
ANSAP No.: 0384 Valid Until: Lifetime Member
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: M.AN.

Supervised by: AMELITA D. DUMAGUIN Noted by: ZENAIDA M. BAUTISTA Approved by: MARIA TERESA R. FAJARDO
Clinical Instructor Clinical Coordinator Dean
Date signed: PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: 0160104 Valid Until: September 9, 2013
Degree: BSN, RN PNA No.: 040412 Valid Until: October 31, 2011 PNA No.: 040351 Valid Until: October 31, 2011
PRC I.D. No.: 0243044 Valid Until: December 15, 2012 Date document is signed: Time: ADPCN No.: 19482 Valid Until: May 2011
PNA No.: 040322 Valid Until: December 31, 2011 Please specify Highest Nursing Degree Earned: MAN Date document is signed: Time:
Please specify Highest Nursing Degree Earned: MAN
 UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City University Seal
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: CORPUZ, Rezi Aquino First course (if any):

School graduated from:
Year:
Year of admission in the BSN Program: June 2008
Year graduated from BSN Program: 2011

II. MINOR OPERATION

TIME of PATIENT’S
DATE of OPERATION INITIALS OPERATION TYPE of NAME of NAME of
No. DIAGNOSIS Name & Signature of Qualified Clinical Instructor
OPERATION STARTED- PERFORMED ANESTHESIA SURGEON HOSPITAL
ENDED CASE NO.
(+) 5cm Lacerated
S.E.N.
09:00 PM – 1% lidocaine Dra. Ginalyn R.
1 April 26, 2010 Wound at the Wound Suturing CDVMH Melissa Lou L. Nava, RN
09:30 PM
60340 local Malalis
Back
LEGEND: CDVMH = Col. Domingo A. Valdez Memorial Hospital (Primary)

Prepared by:
REZI A. CORPUZ Concurred by: NIDA G. QUILON
Student CDVMH, Chief Nurse
PRC I.D. No.: 01197801 Valid Until: March 17, 2011
PNA No.: 13609 Valid Until: Lifetime member
ANSAP No.: 090046 Valid Until: December 31. 2011
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: BSN RN MPH 27 units

Supervised by: MELISSA LOU L. NAVA Noted by: ZENAIDA M. BAUTISTA Approved by: MARIA TERESA R. FAJARDO
Clinical Instructor Clinical Coordinator Dean
Date signed: September 17, 2010 PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: 0160104 Valid Until: September 9, 2013
Degree: BSN-R.N. PNA No.: 040412 Valid Until: October 31, 2011 PNA No.: 040351 Valid Until: October 31, 2011
PRC I.D. No.: 0489340 Valid Until: March 18, 2011 Date document is signed: Time: ADPCN No.: 19482 Valid Until: May 2011
PNA No.: 014167 Valid Until: October 31, 2010 Please specify Highest Nursing Degree Earned: MAN Date document is signed: Time:
Please specify Highest Nursing Degree Earned: MAN
 UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City University Seal
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: CORPUZ, Rezi Aquino First course (if any):
School graduated from:
Year:
Year of admission in the BSN Program: June 2008
Year graduated from BSN Program: 2011

IV. ASSISTED DELIVERY

MOTHER’S
DATE of TIME of GENDER of TYPE NAME of
No. DIAGNOSIS INITIALS AGE Name & Signature of Qualified Clinical Instructor
DELIVERY DELIVERY BABY of DELIVERY HOSPITAL
CASE NO.
Pregnancy Uterine Full
Term, 41 Weeks Age of M.D.E.
Normal Spontaneous
1 Gestation, Cephalic 32 April 25, 2010 03:10 A.M. Female CDVMH Melissa Lou L. Nava, RN
Delivery
Presentation, Alive, 16043
Gravida 3 Para 3 (3-0-0-3)
LEGEND: CDVMH = Col. Domingo A. Valdez Memorial Hospital (Primary)

Prepared by:
REZI A. CORPUZ Concurred by: NIDA G. QUILON
CDVMH, Chief Nurse
Student
PRC I.D. No.: 01197801 Valid Until: March 17, 2011
PNA No.: 13609 Valid Until: Lifetime member
ANSAP No.: 090046 Valid Until: December 31. 2011
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: BSN RN MPH 27 units

Approved by: MARIA TERESA R. FAJARDO

Supervised by: MELISSA LOU L. NAVA Noted by: ZENAIDA M. BAUTISTA Dean
Clinical Instructor Clinical Coordinator PRC I.D. No.: 0160104 Valid Until: September 9, 2013
Date signed: September 17, 2010 PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 040351 Valid Until: October 31, 2011
Degree: BSN-R.N. PNA No.: 040412 Valid Until: October 31, 2011 ADPCN No.: 19482 Valid Until: May 2011
PRC I.D. No.: 0489340 Valid Until: March 18, 2011 Date document is signed: Time: Date document is signed: Time:
PNA No.: 014167 Valid Until: October 31, 2010 Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN