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Cebu Doctors’ University

Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION
Cebu Regional Office

COLLEGE OF NURSING
# 1 Dr. P.V. Larrazabal Jr. Avenue, North Reclamation
6014 Mandaue City, Cebu, Philippines

Name of Student: ______________________________________________________________________________________________________________________________________
Accreditation Level (if any): ____________________________________ Year Granted:__________________________________________________________________________________
Date School/Program was Recognized: _____________________________ Number:_____________________________________________________ Year: ________________________
First Course (if any): ________________________________ School Graduated From:_________________________________________________________ Year: ____________________
Year of Admission in the Bachelor of Science in Nursing Program:__________________________________________________________________________________________________
Year Graduated (BSN Program): _____________________________________________________________________________________________________________________________

No.

Date of
Operation

Case
No.

Name
of
Patient

Diagnosis

1.

2.

3.

4.

5.

Prepared by: ___________________________________
Name & Signature

I. Major Operations
Operation
Type of
Performed
Anesthesia

Name of
Surgeon

Name of
Hospital

Name and Signature
of O.R. Scrub Nurse

Supervised by:
Name & Signature of
Qualified C.I.

: _______________________ Valid until: ________________________ __________________________________ Signature over printed name of Chief Nurse Date signed: _______________________ Degree: __________________________ a.I.) PNA No.) PNA No.) PNA No.) PRC No.: ______________________ Valid until: _______________________ b.) PRC No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed Name of Clinical Coordinator Date Signed: _______________________ Degree: ___________________________ a.: _______________________ Valid until: _______________________ b.Supervised By: Noted By: Concurred by: Approved by: __________________________________ Signature over printed Name of Qualified C.: _______________________ Valid until: ________________________ b. Date Signed: _______________________ Degree: ___________________________ a.:________________________ Valid Until:___________________________ .) PRCNo.) PNA No.:________________________ Valid until: _______________________ ____________________________________ Signature over printed Name of Dean Date Signed:__________________________ Degree:______________________________ a.) ADPCN No.) PRC No.:___________________________ Valid Until:___________________________ c.:___________________________ Valid until:___________________________ b.

Avenue.Republic of the Philippines PROFESSIONAL REGULATION COMMISSION Cebu Regional Office Cebu Doctors’ University COLLEGE OF NURSING # 1 Dr. Prepared by: ___________________________________ Name & Signature II. Larrazabal Jr. Name of Patient Diagnosis 1. 2. . 4. Date of Operation Case No. Philippines Name of Student:____________________________________________________________________________________________________________________________________________ Accreditation Level (if any): ____________________________________ Year Granted:___________________________________________________________________________________ Date School/Program was Recognized: _____________________________ Number: ___________________________________________________________ Year:____________________ First Course (if any): ________________________________ School Graduated From: __________________________________________________________ Year:____________________ Year of Admission in the Bachelor of Science in Nursing Program:_____________________________________________________________________________________________________ Year Graduated (BSN Program):_______________________________________________________________________________________________________________________________ No.R. Cebu. 3. 5. P. Minor Operations Operation Type of Performed Anesthesia Name of Surgeon Name of Hospital Name and Signature of O. Scrub Nurse Supervised by: Name & Signature of Qualified C.V. North Reclamation 6014 Mandaue City.I.

: _______________________ Valid until: _______________________ b.: _______________________ Valid until: ________________________ b.) PRC No.Supervised By: Noted By: Concurred by: Approved by: __________________________________ Signature over printed Name of Qualified C.) PRC No.:________________________ Valid until: _______________________ ____________________________________ Signature over printed Name of Dean Date Signed:__________________________ Degree:______________________________ a.:___________________________ Valid Until:___________________________ c.) PRC No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed name of Chief Nurse Date signed: _______________________ Degree: __________________________ a.) PNA No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed Name of Clinical Coordinator Date Signed: _______________________ Degree: ___________________________ a.) PNA No.) PNA No. Date Signed: _______________________ Degree: ___________________________ a.) PNA No.:________________________ Valid Until:___________________________ .) PRCNo.I.: ______________________ Valid until: _______________________ b.:___________________________ Valid until:___________________________ b.) ADPCN No.

Diagnosis Name of Mother 1. Actual Deliveries Date of Time of Delivery Delivery Gender of Baby Name of Hospital Type of Delivery Supervised by: Name & Signature of Qualified C. Larrazabal Jr. Case No. Prepared by: ___________________________________ Name & Signature Age III. 2.I. P. Avenue.Republic of the Philippines PROFESSIONAL REGULATION COMMISSION Cebu Regional Office Cebu Doctors’ University COLLEGE OF NURSING # 1 Dr. Philippines Name of Student:____________________________________________________________________________________________________________________________________________ Accreditation Level (if any): ____________________________________ Year Granted:___________________________________________________________________________________ Date School/Program was Recognized: _____________________________ Number:_______________________________________________________ Year: ________________________ First Course (if any): ________________________________ School Graduated From:______________________________________________________ Year: ________________________ Year of Admission in the Bachelor of Science in Nursing Program: _____________________________________________________________________________________________________ Year Graduated (BSN Program):_______________________________________________________________________________________________________________________________ No. North Reclamation 6014 Mandaue City. 4. . 5. 3.V. Cebu.

:________________________ Valid until: _______________________ ____________________________________ Signature over printed Name of Dean Date Signed:__________________________ Degree:______________________________ a.:___________________________ Valid until:___________________________ b.: ______________________ Valid until: _______________________ b.:___________________________ Valid Until:___________________________ c.Supervised By: Noted By: Concurred by: Approved by: __________________________________ Signature over printed Name of Qualified C. Date Signed: _______________________ Degree: ___________________________ a.) ADPCN No.:________________________ Valid until:__________________________ .: _______________________ Valid until: ________________________ b.) PRC No.: _______________________ Valid until: _______________________ b.) PNA No.) PRCNo.: _______________________ Valid until: ________________________ __________________________________ Signature over printed name of Chief Nurse Date signed: _______________________ Degree: __________________________ a.) PRC No.I.) PNA No.) PNA No.) PRC No.) PNA No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed Name of Clinical Coordinator Date Signed: _______________________ Degree: ___________________________ a.

I. North Reclamation 6014 Mandaue City. 2. Diagnosis 1.Republic of the Philippines PROFESSIONAL REGULATION COMMISSION Cebu Regional Office Cebu Doctors’ University COLLEGE OF NURSING # 1 Dr. 3. 5. Case No. 4. Prepared by: ___________________________________ Name & Signature Name of Patient Age IV. Deliveries Assisted Date of Time of Delivery Delivery Gender of Baby Name of Hospital Type of Delivery Supervised by: Name & Signature of Qualified C.V. P. Cebu. Larrazabal Jr. Philippines Name of Student:____________________________________________________________________________________________________________________________________________ Accreditation Level (if any): ____________________________________ Year Granted:___________________________________________________________________________________ Date School/Program was Recognized: _____________________________ Number:________________________________________________________ Year: _______________________ First Course (if any): ________________________________ School Graduated From: _______________________________________________________ Year: ______________________ Year of Admission in the Bachelor of Science in Nursing Program:_____________________________________________________________________________________________________ Year Graduated (BSN Program):_______________________________________________________________________________________________________________________________ No. . Avenue.

) PNA No.: ______________________ Valid until: _______________________ b.:___________________________ Valid until:___________________________ b.:___________________________ Valid Until:___________________________ c.Supervised By: Noted By: Concurred by: Approved by: __________________________________ Signature over printed Name of Qualified C.:________________________ Valid until: _______________________ ____________________________________ Signature over printed Name of Dean Date Signed:__________________________ Degree:______________________________ a.) PRC No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed name of Chief Nurse Date signed: _______________________ Degree: __________________________ a.: _______________________ Valid until: ________________________ b.) PNA No.: _______________________ Valid until: _______________________ b.) PRCNo.) PNA No.I. Date Signed: _______________________ Degree: ___________________________ a.) PRC No.:________________________ Valid until:__________________________ .) ADPCN No.) PNA No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed Name of Clinical Coordinator Date Signed: _______________________ Degree: ___________________________ a.) PRC No.

North Reclamation 6014 Mandaue City. Prepared by: ___________________________________ Name & Signature Gender of Baby V.V. 5. . Date Performed Name of Baby 1. Philippines Name of Student:____________________________________________________________________________________________________________________________________________ Accreditation Level (if any): ____________________________________ Year Granted:___________________________________________________________________________________ Date School/Program was Recognized: _____________________________ Number:________________________________________________________ Year: _______________________ First Course (if any): ________________________________ School Graduated From:_______________________________________________________ Year: _______________________ Year of Admission in the Bachelor of Science in Nursing Program:_____________________________________________________________________________________________________ Year Graduated (BSN Program):_______________________________________________________________________________________________________________________________ No. Larrazabal Jr. Case No. P. 3. Cebu. 2.Republic of the Philippines PROFESSIONAL REGULATION COMMISSION Cebu Regional Office Cebu Doctors’ University COLLEGE OF NURSING # 1 Dr. Cord Dressing Name of Mother Age Name of Hospital Supervised by: Name & Signature of Qualified C. 4. Avenue.I.

) PNA No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed Name of Clinical Coordinator Date Signed: _______________________ Degree: ___________________________ a.I.: _______________________ Valid until: ________________________ b.) PRC No.: _______________________ Valid until: ________________________ __________________________________ Signature over printed name of Chief Nurse Date signed: _______________________ Degree: __________________________ a.:________________________ Valid until: _______________________ ____________________________________ Signature over printed Name of Dean Date Signed:__________________________ Degree:______________________________ a.) PNA No.) PNA No.) PRC No.:___________________________ Valid Until:___________________________ c.: ______________________ Valid until: _______________________ b.) PRC No.) PNA No.: _______________________ Valid until: _______________________ b.:________________________ Valid until:__________________________ .:___________________________ Valid until:___________________________ b.) PRCNo. Date Signed: _______________________ Degree: ___________________________ a.) ADPCN No.Supervised By: Noted By: Concurred by: Approved by: __________________________________ Signature over printed Name of Qualified C.