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Republic of the Philippines

Professional Regulation Commission
Manila

Name of Student: ________________________________________________________________________________________________________________________________________________________

Name & Address of School: UNIVERSITY OF SAN JOSE RECOLETOS, COLLEGE OF NURSING, MAGALLANES ST., CEBU CITY _______________________________________________________________________
Accreditation Level: (if any): FULL GOVERNMENT RECOGNITION Year Granted: 2008______________________________________________________________________
Date School/Program was recognized: SY 2007 – 2008 _____________________________________ Number: 024 ___________________________________ Year: 2008 _____________________________
First Course (if any): (should be filled up by second coursers only)_____________________________School Graduated From: (should be filled up by second coursers only) Year: (should be filled up by second coursers
only)
Year of Admission in the Bachelor of Science in Nursing Program: 2006 ______________________________________________________________________________________________________________
Year Graduated (BSN program): 2010 __________________________________________________________________________________________________________________________________________

I. Minor Operations
No. Date of Case Name of Patient Diagnosis Operation Type of Name of Name of Name of O.R. Signature Signature over
Operation No. Performed Anesthesia Surgeon Hospital Scrub Nurse of O.R. Printed Name of
Scrub Clinical
Nurse Instructor

1.

2.

3.

Prepared by:

______________________________
Name of Student
Supervised by: Noted by: Concurred by: Approved by:
MR. EMILIANO IAN B. SUSON II MRS. MARIBEC V. DELDA ____________________ MRS. LUZ L. BORROMEO
Signature over printed name of Faculty 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:________________________ Date Signed:_____________________
Degree :BSN., RN., MAN Degree :BSN., RN., MAN Degree :_______________ Degree :BSN., RN., MN
a.) PRC No :0321033 a.) PRC No. :80543 a.) PRC No. :_______________ a.) PRC No. :0061246
Valid until: :NOVEMBER 18, 2009 Valid until :APRIL 12, 2011 Valid until :_______________ Valid until :JULY 18, 2011
b. PNA No. :_______________ b.) PNA No. :16018 b.) PNA No. :_______________ b.) PNA No. : 10890
Valid until :_______________ Valid until :LIFETIME Valid until :_______________ Valid until : LIFETIME
c.) ANSAP :_______________ c.) ADPCN No. :079
Valid until :_______________ Valid until :DECEMBER 31, 2010
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
___________________________________
Signature of Applicant
Subscribed and sworn to before me _______ day of ____________________ 20______, ________________________, Philippines.

NOTARY PUBLIC