REPUBLIC OF THE PHILIPPINES

PROFESSIONAL REGULATION COMMISSION

BOARD OF NURSING
Prepared by:
Name of Student: ___________________________
_____________________________
Name and Address of School: Far Eastern University, Nicanor Reyes Sr. Street, Sampaloc, Manila 1008

Accreditation Level: Level II PAASCU Re-Accredited __________________________________________________________________________________Year Granted:

_________
Date School/ Program was recognized: April 10, 1958 Number: 66 Year: 1958

First Course (if any): ____ School Graduated from:

______________
Year of Admission in the Bachelor of Science in Nursing Program:__

Year Graduate (BSN Program): __

I. MAJOR OPERATIONS

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

Noted by: Concurred by: Concurred by: Approved by:

ELIZABETH F. HACIÑAS, RN, RM, MAN _________________________________________________ _________________________________________________ GLENDA S. ARQUIZA, RN, PhD ____
___ Signature over printed Name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Signature over printed Name of Clinical Date Signed: Date Signed: Date Signed: _________
Coordinator Degree: _________________________________________ Degree: _________________________________________ Degree: Doctor of Philosophy, Major in
Date Signed: a.) PRC No.: ______ _________ a.) PRC No.: ______ _________ Educational Administration
Degree: Master of Arts in Nursing Valid until: _________ ________ Valid until: _________ ________ a.) PRC No.: 0043483 ____
_________ _________ _________ Valid until: December 31, 2010 ___
a.) PRC No.: 0101726 b.) PNA No.: _ _________ _________ b.) PNA No.: _ _________ _________ b.) PNA No.: 19071 ____
Valid until: July 01, 2011 Valid until: _________________ Valid until: _________________ Valid until: Lifetime ____
b.) PNA No.: 4870 c.) ANSAP No.: c.) ANSAP No.: c.) ADPCN No.: 0786 ____
Valid until: Lifetime Valid until: ____________________________ Valid until: ____________________________ Valid until: December 31, 2010
____
REPUBLIC OF THE PHILIPPINES
PROFESSIONAL REGULATION COMMISSION
BOARD OF NURSING
Prepared by:
Name of Student: ___________________________
_____________________________
Name and Address of School: Far Eastern University, Nicanor Reyes Sr. Street, Sampaloc, Manila 1008

Accreditation Level: Level II PAASCU Re-Accredited __________________________________________________________________________________Year Granted: _

_________
Date School/ Program was recognized: April 10, 1958 Number: 66 Year: 1958

First Course (if any): ____ School Graduated from:

______________
Year of Admission in the Bachelor of Science in Nursing Program:__

Year Graduate (BSN Program): __

II. MINOR OPERATIONS

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

3
 4

Noted by: Concurred by: Concurred by: Approved by:

ELIZABETH F. HACIÑAS, RN, RM, MAN _________________________________________________ _________________________________________________ GLENDA S. ARQUIZA, RN, PhD ____
___ Signature over printed Name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Signature over printed Name of Clinical Date Signed: Date Signed: Date Signed: _________
Coordinator Degree: _________________________________________ Degree: _________________________________________ Degree: Doctor of Philosophy, Major in
Date Signed: a.) PRC No.: ______ _________ a.) PRC No.: ______ _________ Educational Administration
Degree: Master of Arts in Nursing Valid until: _________ ________ Valid until: _________ ________ a.) PRC No.: 0043483 ____
_________ _________ _________ Valid until: December 31, 2010 ___
a.) PRC No.: 0101726 b.) PNA No.: _ _________ _________ b.) PNA No.: _ _________ _________ b.) PNA No.: 19071 ____
Valid until: July 01, 2011 Valid until: _________________ Valid until: _________________ Valid until: Lifetime ____
b.) PNA No.: 4870 c.) ANSAP No.: c.) ANSAP No.: c.) ADPCN No.: 0786 ____
Valid until: Lifetime Valid until: ____________________________ Valid until: ____________________________ Valid until: December 31, 2010
____
REPUBLIC OF THE PHILIPPINES
PROFESSIONAL REGULATION COMMISSION
BOARD OF NURSING
Prepared by:
Name of Student: ___________________________
_____________________________
Name and Address of School: Far Eastern University, Nicanor Reyes Sr. Street, Sampaloc, Manila 1008

Accreditation Level: Level II PAASCU Re-Accredited __________________________________________________________________________________Year Granted: _

_________
Date School/ Program was recognized: April 10, 1958 Number: 66 Year: 1958

First Course (if any): ____ School Graduated from:

______________
Year of Admission in the Bachelor of Science in Nursing Program:__

Year Graduate (BSN Program): __

III. ACTUAL DELIVERIES

No Case No. Diagnosis Name of Mother Age Date of Time Gender of Name of Hospital Type of Supervised by
. Delivery of Baby Delivery (Name & Signature of
Delive Qualified Clinical
ry Instructor)
 1

Noted by: Concurred by: Concurred by: Approved by:

ELIZABETH F. HACIÑAS, RN, RM, MAN _________________________________________________ _________________________________________________ GLENDA S. ARQUIZA, RN, PhD ____
___ Signature over printed Name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Signature over printed Name of Clinical Date Signed: Date Signed: Date Signed: _________
Coordinator Degree: _________________________________________ Degree: _________________________________________ Degree: Doctor of Philosophy, Major in
Date Signed: a.) PRC No.: ______ _________ a.) PRC No.: ______ _________ Educational Administration
Degree: Master of Arts in Nursing Valid until: _________ ________ Valid until: _________ ________ a.) PRC No.: 0043483 ____
_________ _________ _________ Valid until: December 31, 2010 ___
a.) PRC No.: 0101726 b.) PNA No.: _ _________ _________ b.) PNA No.: _ _________ _________ b.) PNA No.: 19071 ____
Valid until: July 01, 2011 Valid until: _________________ Valid until: _________________ Valid until: Lifetime ____
b.) PNA No.: 4870 c.) ANSAP No.: c.) ANSAP No.: c.) ADPCN No.: 0786 ____
Valid until: Lifetime Valid until: ____________________________ Valid until: ____________________________ Valid until: December 31, 2010
____
REPUBLIC OF THE PHILIPPINES
PROFESSIONAL REGULATION COMMISSION
BOARD OF NURSING
Prepared by:
Name of Student: ___________________________
_____________________________
Name and Address of School: Far Eastern University, Nicanor Reyes Sr. Street, Sampaloc, Manila 1008

Accreditation Level: Level II PAASCU Re-Accredited __________________________________________________________________________________Year Granted: ___

_________
Date School/ Program was recognized: April 10, 1958 Number: 66 Year: 1958

First Course (if any): ____ School Graduated from:

______________
Year of Admission in the Bachelor of Science in Nursing Program:__
Year Graduate (BSN Program): __

IV. DELIVERIES ASSISTED

No Case No. Diagnosis Name of Mother Age Date of Time Gender of Name of Hospital Type of Supervised by
. Delivery of Baby Delivery (Name & Signature of
Delive Qualified Clinical
ry Instructor)

Noted by: Concurred by: Concurred by: Approved by:

ELIZABETH F. HACIÑAS, RN, RM, MAN _________________________________________________ _________________________________________________ GLENDA S. ARQUIZA, RN, PhD ____
___ Signature over printed Name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Signature over printed Name of Clinical Date Signed: Date Signed: Date Signed: _________
Coordinator Degree: _________________________________________ Degree: _________________________________________ Degree: Doctor of Philosophy, Major in
Date Signed: a.) PRC No.: ______ _________ a.) PRC No.: ______ _________ Educational Administration
Degree: Master of Arts in Nursing Valid until: _________ ________ Valid until: _________ ________ a.) PRC No.: 0043483 ____
_________ _________ _________ Valid until: December 31, 2010 ___
a.) PRC No.: 0101726 b.) PNA No.: _ _________ _________ b.) PNA No.: _ _________ _________ b.) PNA No.: 19071 ____
Valid until: July 01, 2011 Valid until: _________________ Valid until: _________________ Valid until: Lifetime ____
b.) PNA No.: 4870 c.) ANSAP No.: c.) ANSAP No.: c.) ADPCN No.: 0786 ____
Valid until: Lifetime Valid until: ____________________________ Valid until: ____________________________ Valid until: December 31, 2010
____
REPUBLIC OF THE PHILIPPINES
PROFESSIONAL REGULATION COMMISSION
BOARD OF NURSING
Prepared by:
Name of Student: ___________________________
_____________________________
Name and Address of School: Far Eastern University, Nicanor Reyes Sr. Street, Sampaloc, Manila 1008

Accreditation Level: Level II PAASCU Re-Accredited __________________________________________________________________________________Year Granted:

_________
Date School/ Program was recognized: April 10, 1958 Number: 66 Year: 1958

First Course (if any): ____ School Graduated from:

______________
Year of Admission in the Bachelor of Science in Nursing Program:__

Year Graduate (BSN Program): __

V. CORD DRESSING

No Case No. Date Name of Baby Gender of Baby Name of Mother Age Name of Hospital Supervised by
. Performed (Name & Signature of Qualified
Clinical Instructor)

Noted by: Concurred by: Concurred by: Approved by:

ELIZABETH F. HACIÑAS, RN, RM, MAN _________________________________________________ _________________________________________________ GLENDA S. ARQUIZA, RN, PhD ____
___ Signature over printed Name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Signature over printed Name of Clinical Date Signed: Date Signed: Date Signed: _________
Coordinator Degree: _________________________________________ Degree: _________________________________________ Degree: Doctor of Philosophy, Major in
Date Signed: a.) PRC No.: ______ _________ a.) PRC No.: ______ _________ Educational Administration
Degree: Master of Arts in Nursing Valid until: _________ ________ Valid until: _________ ________ a.) PRC No.: 0043483 ____
_________ _________ _________ Valid until: December 31, 2010 ___
a.) PRC No.: 0101726 b.) PNA No.: _ _________ _________ b.) PNA No.: _ _________ _________ b.) PNA No.: 19071 ____
Valid until: July 01, 2011 Valid until: _________________ Valid until: _________________ Valid until: Lifetime ____
b.) PNA No.: 4870 c.) ANSAP No.: c.) ANSAP No.: c.) ADPCN No.: 0786 ____
Valid until: Lifetime Valid until: ____________________________ Valid until: ____________________________ Valid until: December 31, 2010
____