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FAR EASTERN UNIVERSITY

Prepared by: Name of Student: ______________________________

Name and Address of School: Far Eastern University, Nicanor Reyes Sr. Street, Sampaloc, Manila 1008 Accreditation Level: Level III PAASCU Re-accredited Date School/ Program was Recognized: April 10, 1958 First Course (if any): None Applicable Year of Admission in the Bachelor of Science in Nursing Program:____ Year Graduate (BSN Program):____ Number: 66 Year Granted: March 31, 2001 Year: 1958 School Graduated from: Not

I. MAJOR OPERATIONS No . Date of Operati on Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name and Signature of O.R. Scrub Nurse Supervised by (Name & Signature of Qualified Clinical Instructor)

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Date of Operati on Case No.: Valid until: ____________________ b.) ADPCN No.) PNA No.: ___ Valid until: c.) PRC No.: 0076582 Valid until: September 2009 b. Minor in Statistics a.D.: 28832 Valid until: Lifetime c.) PNA No.: 17766 Valid until: Lifetime _______________________________ Signature over printed Name of Chief Nurse Date Signed: Degree:_______________ a. RN. BORROMEO.R. Ph. MINOR OPERATIONS No . Sampaloc.: 0642 Valid until: December 2009 FAR EASTERN UNIVERSITY Prepared by: Name of Student: ______________________________ Name and Address of School: Far Eastern University. Street. MAN Signature over printed Name of Clinical Coordinator Date Signed: Degree: Master of Arts in Nursing a.: 0070068 Valid until: June 2009 b. RN. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name and Signature of O.) ANSAP No. 2001 Year: 1958 School Graduated from: Not II. Nicanor Reyes Sr.GLORIA G. Manila 1008 Accreditation Level: Level II PAASCU Re-accredited Date School/ Program was Recognized: April 10. Scrub Nurse Supervised by (Name & Signature of Qualified Clinical Instructor) 1 2 3 .) PNA No. 1958 First Course (if any): None Applicable Year of Admission in the Bachelor of Science in Nursing Program:____ Year Graduate (BSN Program):____ Number: 66 Year Granted: March 31.) PRC No. YANG. CNS Signature over printed Name of Dean Date Signed: Degree: Doctor of Philosophy in Nursing.: Valid until: ANNABELLE R.) PRC No.

2001 Year: 1958 School Graduated from: Not III.: 28832 Valid until: Lifetime c. MAN Signature over printed Name of Clinical Coordinator Date Signed: Degree: Master of Arts in Nursing a.: Valid until: Noted by: ANNABELLE R. Ph.) PNA No. YANG.) ADPCN No.D.) ANSAP No.: 0642 Valid until: December 2009 FAR EASTERN UNIVERSITY Prepared by: Name of Student: ______________________________ Name and Address of School: Far Eastern University.: 0076582 Valid until: September 2009 b.) PNA No. Nicanor Reyes Sr.) PRC No. BORROMEO. Diagnosis Name of Mother Age Date of Delivery Time of Delive ry Gender of Baby Name of Hospital Type of Delivery Supervised by (Name & Signature of Qualified Clinical Instructor) . Manila 1008 Accreditation Level: Level II PAASCU Re-accredited Date School/ Program was Recognized: April 10. RN.4 5 Noted by: GLORIA G. ACTUAL DELIVERIES No . Sampaloc. 1 Case No.: Valid until: ____________________ b. Street.: ___ Valid until: c. CNS Signature over printed Name of Dean Date Signed: Degree: Doctor of Philosophy in Nursing.: 17766 Valid until: Lifetime Concurred by: _______________________________ Signature over printed Name of Chief Nurse Date Signed: Degree:_______________ a. 1958 First Course (if any): None Applicable Year of Admission in the Bachelor of Science in Nursing Program:____ Year Graduate (BSN Program):____ Number: 66 Year Granted: March 31. Minor in Statistics a.) PNA No.: 0070068 Valid until: June 2009 b.) PRC No. RN.) PRC No.

BORROMEO.) PRC No.) PRC No. 2001 Year: 1958 School Graduated from: Not . Minor in Statistics a.) PNA No.) ADPCN No. CNS Signature over printed Name of Dean Date Signed: Degree: Doctor of Philosophy in Nursing. RN.: Valid until: Noted by: ANNABELLE R. Ph.2 3 4 5 Noted by: GLORIA G.) ANSAP No.D. MAN Signature over printed Name of Clinical Coordinator Date Signed: Degree: Master of Arts in Nursing a. Street.: 0642 Valid until: December 2009 FAR EASTERN UNIVERSITY Prepared by: Name of Student: ______________________________ Name and Address of School: Far Eastern University.) PNA No.: 17766 Valid until: Lifetime Concurred by: _______________________________ Signature over printed Name of Chief Nurse Date Signed: Degree:_______________ a.: 0070068 Valid until: June 2009 b. YANG. Nicanor Reyes Sr.) PRC No.: ___ Valid until: c. Manila 1008 Accreditation Level: Level II PAASCU Re-accredited Date School/ Program was Recognized: April 10. 1958 First Course (if any): None Applicable Year of Admission in the Bachelor of Science in Nursing Program:____ Number: 66 Year Granted: March 31.: 0076582 Valid until: September 2009 b.: 28832 Valid until: Lifetime c.) PNA No.: Valid until: ____________________ b. RN. Sampaloc.

) PNA No.) PRC No. Ph. RN.: 0076582 Valid until: September 2009 b. YANG.) PRC No. BORROMEO. Diagnosis Name of Mother Age Date of Delivery Time of Delive ry Gender of Baby Name of Hospital Type of Delivery Supervised by (Name & Signature of Qualified Clinical Instructor) 2 3 4 5 Noted by: GLORIA G.: Valid until: Noted by: ANNABELLE R. RN.) PNA No.) ADPCN No.: ___ Valid until: c. DELIVERIES ASSISTED No .: 0070068 Valid until: June 2009 b.: 17766 Valid until: Lifetime Concurred by: _______________________________ Signature over printed Name of Chief Nurse Date Signed: Degree:_______________ a. MAN Signature over printed Name of Clinical Coordinator Date Signed: Degree: Master of Arts in Nursing a.) ANSAP No. Minor in Statistics a.) PNA No.D.: 0642 Valid until: December 2009 FAR EASTERN UNIVERSITY Prepared by: Name of Student: ______________________________ .Year Graduate (BSN Program):____ IV.: 28832 Valid until: Lifetime c. 1 Case No.) PRC No. CNS Signature over printed Name of Dean Date Signed: Degree: Doctor of Philosophy in Nursing.: Valid until: ____________________ b.

MAN Signature over printed Name of Clinical Coordinator Date Signed: Degree: Master of Arts in Nursing a. Ph. 1 Case No.: 0070068 Valid until: June 2009 b.) PRC No. BORROMEO. 2001 Year: 1958 School Graduated from: Not V.: Valid until: ____________________ b.) PNA No.) PNA No.) ANSAP No.Name and Address of School: Far Eastern University.) PRC No.D.: 17766 Valid until: Lifetime Concurred by: _______________________________ Signature over printed Name of Chief Nurse Date Signed: Degree:_______________ a.) PNA No. Manila 1008 Accreditation Level: Level II PAASCU Re-accredited Date School/ Program was Recognized: April 10.: ___ Valid until: c.: 28832 Valid until: Lifetime c.: 0076582 Valid until: September 2009 b. YANG. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital Supervised by (Name & Signature of Qualified Clinical Instructor) 2 3 4 5 Noted by: GLORIA G. Street. RN. Nicanor Reyes Sr.) ADPCN No.: Valid until: Noted by: ANNABELLE R.) PRC No. RN. CORD DRESSING No . 1958 First Course (if any): None Applicable Year of Admission in the Bachelor of Science in Nursing Program:____ Year Graduate (BSN Program):____ Number: 66 Year Granted: March 31.: 0642 Valid until: December 2009 . Sampaloc. CNS Signature over printed Name of Dean Date Signed: Degree: Doctor of Philosophy in Nursing. Minor in Statistics a.