Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION

Manila

Name of Student: PATRICE ALLYSA C. BENAVIDEZ

Name of School and Address: Catanduanes State University, College of Health Sciences, Virac, Catanduanes
Accredited Level: (If any) ________________________ Year Granted: _____________________
Date School/ Program was Recognized: ____________ Number: _________________________
First Course: (If any) ____________________________ School Graduated From: ____________ Year: ______
Year of Admission in the Bachelor of Science in Nursing Program: _____ Year Graduated (BSN): ______________ Year: ______

WARNING: All statements to verification and any false statement or misinterpretation made in the DOCUMENT is a ground for disqualification and criminal prosecution

II. Minor Operations

Supervised by:
Name & Signature of
Type of
Date of Operation Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital Qualified C.I.
No. Anesthesia
PRC No. ______
Valid Until: ______
1.

2.

3.

Prepared by: Concurred by: Concurred by: Concurred by:

__________________________ __________________________ __________________________

Chief Nurse Chief Nurse Chief Nurse
__________________________________ Date signed: Degree: _______________ Date signed: Degree: _______________ Date signed: Degree: _______________
Student

a. PRC No.: Valid until: _____________ a. PRC No.: Valid until: _____________ a. PRC No.: Valid until: _____________
b. PNA No.: Valid until: _____________ b. PNA No.: Valid until: _____________ b. PNA No.: Valid until: _____________
c. ANSAP No.: Valid until: _____________ c. ANSAP No.: Valid until: _____________ c. ANSAP No.: Valid until: _____________

Approved: SUBSCRIBED AND SWORN before me this

_____________________ _____________________________ at ____________________________________.

Dean Affiant exhibiting to me her Residence Certificate No. _____________________
issued at ________________________ on __________________________.
Date signed: Degree: _______________
a. PRC No.: Valid until: _____________
b. PNA No.: Valid until: _____________
___________________________________________
c. ADPCN No.: Valid until: _____________
Administering Officer or Notary Public