BROKENSHIRE COLLEGE Madapo, Davao City

Name of Student: _____________________________________________ Name and Address of School: Brokenshire College, Madapo, Davao City Accreditation Level: 3 Date School / Program Recognized: June 14, 1983 First Course (if any): ___________________________________________ Year of Admission in the BSN Program:____________________________ Year Graduated ( BSN Program ): ________________________________
No. Date of Operation Case No. Name of Patient Diagnosis

Year Granted: August 2007- April 2012 Number : 012 School Graduated From: ________________________

Year: 1984

MAJOR OPERATIONS
Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name & Sig. of OR Scrub Nurse Supervised by:Name & Sig. of Qualified C.I.

Prepared by : ____________________ Name of Student

Noted by : CHERYL M. REYES, R.N., M.N. Clinical Coordinator Date Signed : Degree: Bachelor of Science in Nursing Master in Nursing a) PRC No. : 0290750 Valid Until : March 29, 2011 b.) PNA No. : 13865 Valid Until : LIFETIME

Concurred by : ______________________ Chief Nurse Date Signed : Degree : a) PRC No. : Valid Until : b.) PNA No. : Valid Until : c.) ANSAP No. : Valid Until :

Approved by : RUBY M. UY, R.N., M.A.N., Ph.D. Dean , Brokenshire College Date Signed : Degree: Bachelor of Science in Nursing Master of Arts in Nursing; DOCTOR OF PHILOSOPHY in EDUCATION ADMINISTRATION a) PRC No. : 0094395 Valid Until : December 9, 2010 b.) PNA No. :11602 Valid Until : LIFETIME c.) ADPCN No. : 0587 FRM-NSG-18A

Valid Until : December 2009

Rev. No. 0001