BICOL UNIVERSITY COLLEGE OF NURSING LEGAZPI CITY

Name of Student: ____________________________________________________________________________________________________________________________________

Accredited 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):_________________________ _
WARNING: All statements are subject to verification and any false statement or misrepresentation made in this DOCUMENT is a ground for disqualification and criminal prosecution.
I. Major Operations
No. Date of Case No. Name of Patient Diagnosis Operation Performed Type of Name of Surgeon Name of Hospital Name of O.R. Scrub Signature of
Operation Anaesthesia Nurse O.R. Scrub
PRC No. __ ____ Nurse
Valid Until: __ __
1

Prepared by: Supervised by: Noted by:

_____________________________________ __________________________________________ __ ______________ ____________________ __________

Student Clinical Instructor Clinical Coordinator
(Signature over printed name) (Signature over printed name) (Signature over printed name)
Date Signed: _________ ______ Degree: ___________________ Date Signed: _________ ______ Degree: ____________________
a.) PRC No.: ________ ____ Valid Until: _________________ a.) PRC No.: ________________ Valid Until: _________
b.) PNA No.: ____ __ __ Valid Until: ___________ _____ b.) PNA No.: ______________ Valid Until: _____ ___
Concurred by: Approved by:

___________________ ________ __________________________________

Chief Nurse Dean
(Signature over printed name) (Signature over printed name)
Date Signed:________________ Degree: _____ Date Signed: ____________ Degree: ____________
a. PRC No.: Valid Until: _________ a.) PRC No.: _________ Valid Until: _________
b. PNA No.: Valid Until: _________ b.) PNA No.: ___________ Valid Until: _________
c. ANSAP No. Valid Until: __________ c.) ADPCN No. __ ___ Valid Until: __________
 BICOL UNIVERSITY COLLEGE OF NURSING LEGAZPI CITY

Name of Student: __________________________ ____________________________________________________________________________________________________________

Accredited 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):_ ________________________ _
WARNING: All statements are subject to verification and any false statement or misrepresentation made in this DOCUMENT is a ground for disqualification and criminal prosecution.
II. Minor Operations
No. Date of Case No. Name of Patient Diagnosis Operation Performed Type of Name of Surgeon Name of Hospital Name of O.R. Scrub Signature of
Operation Anesthesia Nurse O.R. Scrub
PRC No. __ ____ Nurse
Valid Until: __ __
1

Prepared by: Supervised by: Noted by:

_______ ______________________________ ___ _____________________________ ____ __ ________________ ____________________ ________

Student Clinical Instructor Clinical Coordinator
(Signature over printed name) (Signature over printed name) (Signature over printed name)
Date Signed: _________ ______ Degree: ____________________ Date Signed: _______________ Degree:_____________
a.) PRC No.: _______ ____ Valid Until: _________________ a.) PRC No.: ________________ Valid Until:___________
b.) PNA No.: ___________ Valid Until: ___________ _ b.) PNA No.: ______________ Valid Until: _________
Concurred by: Approved by:

___________________ __________ _________________ ________

Chief Nurse Dean
(Signature over printed name) (Signature over printed name)
Date Signed:________________ Degree: _____ Date Signed: ____________ Degree: ____________________
a. PRC No.: Valid Until: _________ a.) PRC No.: ________ Valid Until: _________
b. PNA No.: Valid Until: _________ b.) PNA No.: ___________ Valid Until: _________
c. ANSAP No. Valid Until: _________ c.) ADPCN No. __ ___ Valid Until: __________
 BICOL UNIVERSITY COLLEGE OF NURSING LEGAZPI CITY

Name of Student: ___________________________ ____________________________________________________________________________________________________________

Accredited 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):_ ________________________ _
WARNING: All statements are subject to verification and any false statement or misrepresentation made in this DOCUMENT is a ground for disqualification and criminal prosecution.
III. Actual Deliveries
No. Case No. Diagnosis Name of Patient Age Date of Time of Gender Name of Hospital Type of Delivery Supervised by:
Name & Signature of
Delivery Delivery of Baby
Qualified C.I.
PRC No. ___ ___
Valid Until: _ ___
1

Prepared by: Supervised by: Concurred by:

___ ________________________________ ____________ ___________________________________ ________________ ____

Student Clinical Coordinator Chief Nurse
(Signature over printed name) (Signature over printed name) (Signature over printed name)
Date Signed: Degree: ____________ Date Signed: Degree:
a.) PRC No.: Valid Until: _________ a. PRC No.: Valid Until: __________
b.) PNA No.: _ Valid Until: _________ b. PNA No.: Valid Until: _________
c. ANSAP No. Valid Until: _________
Approved by:

_______________________
Dean
(Signature over printed name)
Date Signed: Degree: ____________________
a.) PRC No.: ________ Valid Until: _________
b.) PNA No.: Valid Until: _________
 c.) ADPCN No. Valid Until:
BICOL UNIVERSITY COLLEGE OF NURSING LEGAZPI CITY

Name of Student: _______________________ _____________________________________________________________________________________________________________

Accredited 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):_________________________ _
WARNING: All statements are subject to verification and any false statement or misrepresentation made in this DOCUMENT is a ground for disqualification and criminal prosecution.
IV. Deliveries Assisted
No. Case No. Diagnosis Name of Patient Age Date of Time of Gender Name of Hospital Type of Delivery Supervised by:
Name & Signature of
Delivery Delivery of Baby
Qualified C.I.
PRC No. ___ ___
Valid Until: _ ___
1

Prepared by: Supervised by: Concurred by:

___ _________________________ _____ ____________ ___________________________________ ________________ ____

Student Clinical Coordinator Chief Nurse
(Signature over printed name) (Signature over printed name) (Signature over printed name)
Date Signed: Degree: _____________ Date Signed: Degree:
a.) PRC No.: ________ Valid Until: _________ a. PRC No.: Valid Until: _________
b.) PNA No.: _ Valid Until: _________ b. PNA No.: Valid Until: ________
c. ANSAP No. Valid Until: _________
Approved by:

_______________________
Dean
(Signature over printed name)
Date Signed: Degree: ___________________
a.) PRC No.: _______ Valid Until: _________
 b.) PNA No.: Valid Until: _________
c.) ADPCN No. Valid Until:
BICOL UNIVERSITY COLLEGE OF NURSING LEGAZPI CITY

Name of Student: _______________________________________________________________________________________________

Accredited 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):_________________________ _
WARNING: All statements are subject to verification and any false statement or misrepresentation made in this DOCUMENT is a ground for disqualification and criminal prosecution.
V. Cord Dressing
No. Case No. Date Performed Name of Baby Gender Name of Mother Age Name of Hospital Supervised by:
Name & Signature of Qualified C.I.
of Baby
PRC No. ___ ___
Valid Until: _ ___

Prepared by: Supervised by: Concurred by:

___ ________________________________ ____________ ___________________________________ ________________ ____

Student Clinical Coordinator Chief Nurse
(Signature over printed name) (Signature over printed name) (Signature over printed name)
Date Signed: Degree: ____________ Date Signed: Degree:
a.) PRC No.: Valid Until: _________ a. PRC No.: Valid Until: _________
b.) PNA No.: _ Valid Until: _________ b. PNA No.: Valid Until: _________
c. ANSAP No. Valid Until: __________
Approved by:

_______________________
Dean
(Signature over printed name)
Date Signed: Degree: ___________________
a.) PRC No.: _______ Valid Until: _________
b.) PNA No.: Valid Until: _________
c.) ADPCN No. Valid Until: