ST.

MARY’S COLLEGE
Tagum City
Name of Student: Michael Roy B. Rodriguez
Name & Address of School: Saint Mary’s College Kilometer 55 National Highway Tagum City
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 of Patient Diagnosis Operatio Type of Name of Name of Name of Signature Supervise
. Operati No. n Anesthe Surgeon Hospital O.R. Scrub of OR d by:
on Perform sia Nurse Scrub Name &
ed Nurse Signature
of
Qualified
C.I.

Prepared by:
Michael Roy B. Rodriguez
Signature over printed name of student

Noted by: Concurred by: Approved by:

Josefina S. Balote, RN, MN Aida C. Hangad, RN,

MAN
Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse
Signature over printed name of Dean
Date Signed: Date Signed: Date Signed:
Degree: Master in Nursing Degree: Degree: Master of Arts in
Nursing
a.) PRC No: 0107556 a.) PRC No: a.) PRC No: 0059664
Valid Until: November 06, 2009 Valid Until: Valid Until:
September 30, 2009
b.) PNA No: 23753 b.) PNA No: b.) PNA No: 11-DN-0015-
1
Valid Until: December Valid Until: Valid Until: Lifetime
member
c.) ANSAP No: c.) ADPCN No: 511
Valid Until: Valid Until: December
2008