FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc Manila 1008 Tel. No.: (632) 735-8713, Fax No.

: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph PAASCU, Level II Re-Accredited, May 2011 MAJOR SURGICAL SCRUB in QUEZON CITY GENERAL HOSPITAL, QUEZON CITY Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student CUMIGAD, MA. GHIEZHEL YATAR

Date Performed and Time Started

Patient’s INITIALS (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)

SUPERVISED BY Clinical Instructor (Name and Signature)

January 6, 2011 8:00 AM

L.M.P. 012220

Craniotomy: Evacuation Of Depressed Fracture Debridement

Ybeth Bitolinamisa RN, MAN

Amelita Miguel, RN, MAN

January 7, 2011 11:40 AM

R.D.C. 012219579312

Appendectomy

Ybeth Bitolinamisa RN, MAN

Amelita Miguel, RN, MAN

Noted by: MONICA C. LAGONOY - AŇONUEVO, RN, MAN Signature over printed name of Clinical Coordinator Date signed: Degree: Master of Arts in Nursing PRC Lic. No. : 0158815 Valid Until: May 4, 2013 PNA No. : 2011-041254 Valid Until: December 2012

Concurred by: MARILOU GUILLERMINA J. PALAFOX, RN, PhD Signature over printed name of Chief Nurse Date signed: Degree: Doctor of Philosophy in Public Administration PRC Lic. No.: 0118849 Valid Until: February 10, 2014 PNA No. : 18459 Valid Until: Lifetime

Approved by: ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD Signature over printed name of Dean Date signed: Degree: Doctor of Philosophy Major in Educational Management PRC Lic. No. : 78564 Valid Until: September 24, 2014 PNA No. : 2159 Valid Until: Lifetime ADPCN No. : 11-351 Valid Until: May 31, 201

No. Nurse on Duty (Name and Signature) SUPERVISED BY Clinical Instructor (Name and Signature) January 6. RN. : 2159 Valid Until: Lifetime ADPCN No.FAR EASTERN UNIVERSITY Nicanor Reyes Sr.AŇONUEVO. RM. MA. : 78564 Valid Until: September 24. 2014 PNA No. 201 .: 0118849 Valid Until: February 10.edu. No. SALUSTIANO.: (632) 736-0010. No.: (632) 735-8713. GHIEZHEL YATAR Date Performed and Time Started Patient’s INITIALS (only) Case Number SURGICAL PROCEDURE PERFORMED O. 2011 11:40 AM R. No. PhD Signature over printed name of Dean Date signed: Degree: Doctor of Philosophy Major in Educational Management PRC Lic.ph.feu. : 0158815 Valid Until: May 4. PALAFOX. RN. : 2011-041254 Valid Until: December 2012 Concurred by: MARILOU GUILLERMINA J. : 18459 Valid Until: Lifetime Approved by: ROSALINDA P.ph PAASCU.M. Municipality/City/Province Prepared by: Printed Name with Signature of Student CUMIGAD. MAN Noted by: MONICA C. RN. MAN January 6. QUEZON CITY Hospital. : 11-351 Valid Until: May 31.R. MAN Amelita Miguel. 2013 PNA No. RN. MAN Signature over printed name of Clinical Coordinator Date signed: Degree: Master of Arts in Nursing PRC Lic. RN.P. Level II Re-Accredited. 012219579312 Appendectomy Ybeth Bitolinamisa RN. Fax No. 2014 PNA No. May 2011 MAJOR SURGICAL SCRUB in QUEZON CITY GENERAL HOSPITAL. PhD Signature over printed name of Chief Nurse Date signed: Degree: Doctor of Philosophy in Public Administration PRC Lic. MAN.edu. Street Sampaloc Manila 1008 Tel. Website: www. 2011 8:00 AM L. LAGONOY . 012220 Craniotomy: Evacuation Of Depressed Fracture Debridement Ybeth Bitolinamisa RN.C. MAN Amelita Miguel. Email: IN@feu.D.