DR. CARLOS S.

LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph

Name of Student:
Name and Address of School: Dr. Carlos S. Lanting College, # 16 Tandang Sora Avenue, Sangandaan, Nov., Quezon City
Accreditation Level: (if any) Year Granted
Date School/Program was Recognized: June 6 Number C – 030 Year 1992
First Course (if any): Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

I. Major Operations
Date of
Case Operation Type of Name of Supervised by:
No. Operati Name of Patient Diagnosis Name of Hospital
No. Performed Anesthesia Surgeon Name & Signature of Qualified C.I.
on

1. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

2. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

3. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

4. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

5. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________
Prepared by:

Signature over printed Name of Student

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

 DR. CARLOS S. LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph

DANIEL H. GAYOD, RN, MAN NORA VELMA M. GAYOD, R.N., M.AN._

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Date Signed: Date Signed:_______________________ Date Signed: Date Signed: _________
Degree: Bachelor of Science in Nursing Degree: __ Degree: Degree: Bachelor of Science in Nursing _
a). PRC No.: 0335718 ______ a).PRC No: ____ ___________ a). PRC No.: a). PRC No.: 0210791
Valid until: September 23, 2012 Valid until:: ____ Valid until: Valid Until: February 12, 2012_______
b). PNA No.: 15981 b).PNA No. ____ ___________ b). PNA No.: b). PNA No.: 15980
Valid until: LIFETIME Valid until: _____ Valid until: Valid Until: LIFETIME
c) ANSAP: _____ ________________ c) ANSAP No: ________________ c). ADPCN No.: 0815_______ _
Valid until: Valid until: ______ Valid until: 2010

Name of Student:
Name and Address of School: Dr. Carlos S. Lanting College, # 16 Tandang Sora Avenue, Sangandaan, Nov., Quezon City
Accreditation Level: (if any) Year Granted
Date School/Program was Recognized: June 6 Number C – 030 Year 1992
First Course (if any): Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

II. Minor Operations

Date of
Case Operation Type of Name of Supervised by:
No. Operati Name of Patient Diagnosis Name of Hospital
No. Performed Anesthesia Surgeon Name & Signature of Qualified C.I.
on

1. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

2. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

3. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________

4. PRC No.:______________ Valid

Until:______________
PNA No.: ______________Valid
Until:______________
 DR. CARLOS S. LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph
5. PRC No.:______________ Valid
Until:______________
PNA No.: ______________Valid
Until:______________
Prepared by:

Signature over printed Name of Student

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

DANIEL H. GAYOD, RN, MAN NORA VELMA M. GAYOD, R.N., M.AN._

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Date Signed: Date Signed:_______________________ Date Signed: Date Signed: _________
Degree: Bachelor of Science in Nursing Degree: __ Degree: Degree: Bachelor of Science in Nursing _
a). PRC No.: 0335718 ______ a).PRC No: ____ ___________ a). PRC No.: a). PRC No.: 0210791
Valid until: September 23, 2012 Valid until:: ____ Valid until: Valid Until: February 12, 2012_______
b). PNA No.: 15981 b).PNA No. ____ ___________ b). PNA No.: b). PNA No.: 15980
Valid until: LIFETIME Valid until: _____ Valid until: Valid Until: LIFETIME
c) ANSAP: _____ ________________ c) ANSAP No: ________________ c). ADPCN No.: 0815_______ _
Valid until: Valid until: ______ Valid until: 2010

Name of Student:
Name and Address of School: Dr. Carlos S. Lanting College, # 16 Tandang Sora Avenue, Sangandaan, Nov., Quezon City
Accreditation Level: (if any) Year Granted
Date School/Program was Recognized: June 6 Number C – 030 Year 1992
First Course (if any): Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

III. Actual Deliveries

Date of Time of Gender of Supervised by:
No. Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery
Delivery Delivery Baby Name & Signature of Qualified C.I.
PRC No.:______________ Valid
1. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

2. Until:______________
PNA No.: ______________Valid
Until:______________
3.
PRC No.:______________ Valid
Until:______________
 DR. CARLOS S. LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

4. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

5. Until:______________
PNA No.: ______________Valid
Until:______________
Prepared by:

Signature over printed Name of Student

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

DANIEL H. GAYOD, RN, MAN NORA VELMA M. GAYOD, R.N., M.AN._

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Date Signed: Date Signed:_______________________ Date Signed: Date Signed: _________
Degree: Bachelor of Science in Nursing Degree: __ Degree: Degree: Bachelor of Science in Nursing _
a). PRC No.: 0335718 ______ a).PRC No: ____ ___________ a). PRC No.: a). PRC No.: 0210791
Valid until: September 23, 2012 Valid until:: ____ Valid until: Valid Until: February 12, 2012_______
b). PNA No.: 15981 b).PNA No. ____ ___________ b). PNA No.: b). PNA No.: 15980
Valid until: LIFETIME Valid until: _____ Valid until: Valid Until: LIFETIME
c) ANSAP: _____ ________________ c) ANSAP No: ________________ c). ADPCN No.: 0815_______ _
Valid until: Valid until: ______ Valid until: 2010

Name of Student:
Name and Address of School: Dr. Carlos S. Lanting College, # 16 Tandang Sora Avenue, Sangandaan, Nov., Quezon City
Accreditation Level: (if any) Year Granted
Date School/Program was Recognized: June 6 Number C – 030 Year 1992
First Course (if any): Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

IV. Deliveries Assisted

Date of Time of Gender of Supervised by:
No. Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery
Delivery Delivery Baby Name & Signature of Qualified C.I.
1.
PRC No.:______________ Valid
 DR. CARLOS S. LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph
Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

2. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

3. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

4. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

5. Until:______________
PNA No.: ______________Valid
Until:______________
Prepared by:

Signature over printed Name of Student

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

DANIEL H. GAYOD, RN, MAN NORA VELMA M. GAYOD, R.N., M.AN._

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Date Signed: Date Signed:_______________________ Date Signed: Date Signed: _________
Degree: Bachelor of Science in Nursing Degree: __ Degree: Degree: Bachelor of Science in Nursing _
a). PRC No.: 0335718 ______ a).PRC No: ____ ___________ a). PRC No.: a). PRC No.: 0210791
Valid until: September 23, 2012 Valid until:: ____ Valid until: Valid Until: February 12, 2012_______
b). PNA No.: 15981 b).PNA No. ____ ___________ b). PNA No.: b). PNA No.: 15980
Valid until: LIFETIME Valid until: _____ Valid until: Valid Until: LIFETIME
c) ANSAP: _____ ________________ c) ANSAP No: ________________ c). ADPCN No.: 0815_______ _
Valid until: Valid until: ______ Valid until: 2010

Name of Student:
Name and Address of School: Dr. Carlos S. Lanting College, # 16 Tandang Sora Avenue, Sangandaan, Nov., Quezon City
Accreditation Level: (if any) Year Granted
Date School/Program was Recognized: June 6 Number C – 030 Year 1992
First Course (if any): Graduated From: Year:
 DR. CARLOS S. LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

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

PRC No.:______________ Valid

1. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

2. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

3. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

4. Until:______________
PNA No.: ______________Valid
Until:______________

PRC No.:______________ Valid

5. Until:______________
PNA No.: ______________Valid
Until:______________
Prepared by:

Signature over printed Name of Student

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

DANIEL H. GAYOD, RN, MAN NORA VELMA M. GAYOD, R.N., M.AN._

Signature over printed Name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed Name of Chief Nurse Signature over printed Name of Dean
Date Signed: Date Signed:_______________________ Date Signed: Date Signed: _________
Degree: Bachelor of Science in Nursing Degree: __ Degree: Degree: Bachelor of Science in Nursing _
a). PRC No.: 0335718 ______ a).PRC No: ____ ___________ a). PRC No.: a). PRC No.: 0210791
Valid until: September 23, 2012 Valid until:: ____ Valid until: Valid Until: February 12, 2012_______
b). PNA No.: 15981 b).PNA No. ____ ___________ b). PNA No.: b). PNA No.: 15980
Valid until: LIFETIME Valid until: _____ Valid until: Valid Until: LIFETIME
 DR. CARLOS S. LANTING COLLEGE
CASAUL GENERAL HOSPITAL
Co
lle
g eo
fNurs
ing
16 Tandang Sora Avenue, Sangandaan, Novaliches
Quezon City, Philippines
Tel. No.: (02)938-7782/(02)938-7789
Telefax No.: (02)939-7229/(02)930-5299
Email add: nursing@lantingcollege.edu.ph website: www.lantingcollege.edu.ph
c) ANSAP: _____ ________________ c) ANSAP No: ________________ c). ADPCN No.: 0815_______ _
Valid until: Valid until: ______ Valid until: 2010