Republic of the Philippines Cebu Doctors’ University

PROFESSIONAL REGULATION COMMISSION COLLEGE OF NURSING

Cebu Regional Office # 1 Dr. P.V. Larrazabal Jr. Avenue, North Reclamation
6014 Mandaue City, Cebu, Philippines

Name of Student: ______________________________________________________________________________________________________________________________________

Accreditation 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 Program): _____________________________________________________________________________________________________________________________

I. Major Operations
No. Date of Case Name Diagnosis Operation Type of Name of Name of Name and Signature Supervised by:
Operation No. of Performed Anesthesia Surgeon Hospital of O.R. Scrub Nurse Name & Signature of
Patient Qualified C.I.

1.

2.

3.

4.

5.

Prepared by: ___________________________________

Name & Signature
Supervised By:
__________________________________
Signature over printed Name of
Qualified C.I.
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: _______________________
b.) PNA No.: _______________________
Valid until: ________________________
Noted By:
__________________________________
Signature over printed Name of
Clinical Coordinator
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: ________________________
b.) PNA No.: _______________________
Valid until: ________________________
Concurred by:
__________________________________
Signature over printed name of
Chief Nurse
Date signed: _______________________
Degree: __________________________
a.) PRC No.: ______________________
Valid until: _______________________
b.) PNA No.:________________________
Valid until: _______________________
Approved by:
____________________________________
Signature over printed Name of Dean
Date Signed:__________________________
Degree:______________________________
a.) PRCNo.:___________________________
Valid until:___________________________
b.) PNA No.:___________________________
Valid Until:___________________________
c.) ADPCN No.:________________________
Valid Until:___________________________
 Republic of the Philippines Cebu Doctors’ University
PROFESSIONAL REGULATION COMMISSION COLLEGE OF NURSING
Cebu Regional Office # 1 Dr. P.V. Larrazabal Jr. Avenue, North Reclamation
6014 Mandaue City, Cebu, Philippines

Name of Student:____________________________________________________________________________________________________________________________________________
Accreditation 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 Program):_______________________________________________________________________________________________________________________________

II. Minor Operations

No. Date of Case Name Diagnosis Operation Type of Name of Name of Hospital Name and Signature Supervised by:
Operation No. of Performed Anesthesia Surgeon of O.R. Scrub Nurse Name & Signature of
Patient Qualified C.I.

1.

2.

3.

4.

5.

Prepared by: ___________________________________

 Name & Signature
Supervised By:
__________________________________
Signature over printed Name of
Qualified C.I.
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: _______________________
b.) PNA No.: _______________________
Valid until: ________________________
Noted By:
__________________________________
Signature over printed Name of
Clinical Coordinator
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: ________________________
b.) PNA No.: _______________________
Valid until: ________________________
Concurred by:
__________________________________
Signature over printed name of
Chief Nurse
Date signed: _______________________
Degree: __________________________
a.) PRC No.: ______________________
Valid until: _______________________
b.) PNA No.:________________________
Valid until: _______________________
Approved by:
____________________________________
Signature over printed Name of Dean
Date Signed:__________________________
Degree:______________________________
a.) PRCNo.:___________________________
Valid until:___________________________
b.) PNA No.:___________________________
Valid Until:___________________________
c.) ADPCN No.:________________________
Valid Until:___________________________
 Republic of the Philippines Cebu Doctors’ University
PROFESSIONAL REGULATION COMMISSION COLLEGE OF NURSING
Cebu Regional Office # 1 Dr. P.V. Larrazabal Jr. Avenue, North Reclamation
6014 Mandaue City, Cebu, Philippines

Name of Student:____________________________________________________________________________________________________________________________________________
Accreditation 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 Program):_______________________________________________________________________________________________________________________________

III. Actual Deliveries

No. Case Diagnosis Name of Age Date of Time of Gender of Name of Type of Supervised by:
No. Mother Delivery Delivery Baby Hospital Delivery Name & Signature of
Qualified C.I.

1.

2.

3.

4.

5.

Prepared by: ___________________________________

 Name & Signature
Supervised By:
__________________________________
Signature over printed Name of
Qualified C.I.
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: _______________________
b.) PNA No.: _______________________
Valid until: ________________________
Noted By:
__________________________________
Signature over printed Name of
Clinical Coordinator
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: ________________________
b.) PNA No.: _______________________
Valid until: ________________________
Concurred by:
__________________________________
Signature over printed name of
Chief Nurse
Date signed: _______________________
Degree: __________________________
a.) PRC No.: ______________________
Valid until: _______________________
b.) PNA No.:________________________
Valid until: _______________________
Approved by:
____________________________________
Signature over printed Name of Dean
Date Signed:__________________________
Degree:______________________________
a.) PRCNo.:___________________________
Valid until:___________________________
b.) PNA No.:___________________________
Valid Until:___________________________
c.) ADPCN No.:________________________
Valid until:__________________________
 Republic of the Philippines Cebu Doctors’ University
PROFESSIONAL REGULATION COMMISSION COLLEGE OF NURSING
Cebu Regional Office # 1 Dr. P.V. Larrazabal Jr. Avenue, North Reclamation
6014 Mandaue City, Cebu, Philippines

Name of Student:____________________________________________________________________________________________________________________________________________
Accreditation 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 Program):_______________________________________________________________________________________________________________________________

IV. Deliveries Assisted

No. Case Diagnosis Name of Patient Age Date of Time of Gender of Name of Type of Supervised by:
No. Delivery Delivery Baby Hospital Delivery Name & Signature of
Qualified C.I.

1.

2.

3.

4.

5.

Prepared by: ___________________________________

Name & Signature
Supervised By:
__________________________________
Signature over printed Name of
Qualified C.I.
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: _______________________
b.) PNA No.: _______________________
Valid until: ________________________
Noted By:
__________________________________
Signature over printed Name of
Clinical Coordinator
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: ________________________
b.) PNA No.: _______________________
Valid until: ________________________
Concurred by:
__________________________________
Signature over printed name of
Chief Nurse
Date signed: _______________________
Degree: __________________________
a.) PRC No.: ______________________
Valid until: _______________________
b.) PNA No.:________________________
Valid until: _______________________
Approved by:
____________________________________
Signature over printed Name of Dean
Date Signed:__________________________
Degree:______________________________
a.) PRCNo.:___________________________
Valid until:___________________________
b.) PNA No.:___________________________
Valid Until:___________________________
c.) ADPCN No.:________________________
Valid until:__________________________
 Republic of the Philippines Cebu Doctors’ University
PROFESSIONAL REGULATION COMMISSION COLLEGE OF NURSING
Cebu Regional Office # 1 Dr. P.V. Larrazabal Jr. Avenue, North Reclamation
6014 Mandaue City, Cebu, Philippines

Name of Student:____________________________________________________________________________________________________________________________________________
Accreditation 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 Program):_______________________________________________________________________________________________________________________________

V. Cord Dressing
No. Case Date Name of Baby Gender of Name of Mother Age Name of Hospital Supervised by:
No. Performed Baby Name & Signature of
Qualified C.I.

1.

2.

3.

4.

5.

Prepared by: ___________________________________

Name & Signature
Supervised By:
__________________________________
Signature over printed Name of
Qualified C.I.
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: _______________________
b.) PNA No.: _______________________
Valid until: ________________________
Noted By:
__________________________________
Signature over printed Name of
Clinical Coordinator
Date Signed: _______________________
Degree: ___________________________
a.) PRC No.: _______________________
Valid until: ________________________
b.) PNA No.: _______________________
Valid until: ________________________
Concurred by:
__________________________________
Signature over printed name of
Chief Nurse
Date signed: _______________________
Degree: __________________________
a.) PRC No.: ______________________
Valid until: _______________________
b.) PNA No.:________________________
Valid until: _______________________
Approved by:
____________________________________
Signature over printed Name of Dean
Date Signed:__________________________
Degree:______________________________
a.) PRCNo.:___________________________
Valid until:___________________________
b.) PNA No.:___________________________
Valid Until:___________________________
c.) ADPCN No.:________________________
Valid until:__________________________