STATEMENT OF UNDERTAKING FROM THE STUDENT

I Mr./Ms. Rae Dominick A. Salva, a Bachelor of Science in Nursing student of the

College of Nursing, University of Northern Philippines; a resident of San Pedro, Narvacan,
Ilocos Sur, do hereby undertake on this day 22nd of (Month) September, 2021 (Year) the
following statements:

1. I hereby declare that all answers/ responses provided in this module are product of my
own understanding, judgment or capacity.
2. I hereby undertake that all answers to the pre- and post-tests are original or not copied
from secondary sources but through my own ability.
3. I promise to abide by all college and university policies and guidelines in distance
learning.
4. I hereby undertake to report to authorities any undesirable actions from my fellow
student in relation to answering the questions in this module.
5. I hereby understand that I am accountable for sanctions or disciplinary measures from
the college, if proven that I am involved in any undesirable activities related to
answering this learning material.
6. I hereby understand all the terms and conditions stated in this Declaration of
Undertaking.

Name of Student: RAE DOMINICK A. SALVA

Signature:____________________________
Date Signed: September 22, 2021

DECLARATION BY PARENT/ GUARDIAN

I Rowena A. Salva, (Mother / Father / Guardian) hereby fully understand and endorse
this statement of declaration of my child/ward. I will do my best to encourage and monitor
my child/ward to observe all the terms and conditions of this Statement of Undertaking.

Name of Guadian: ROWENA A. SALVA

Signature of the Guardian: __________________
Date Signed: September 22, 2021
Noted by:
________________________________________
Signature Over Printed Name of Faculty-in-Charge

__________________________________________
Signature Over Printed Name of the Dean