LYCEUM-NORTHWESTERN UNIVERSITY

College of Nursing
As adapted from the form of PRC

Prepared by: CERALDE, ANGELITA L.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): B.S. Information Technology School Graduated From: AMA Computer College Year: 2004
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

I. Major Operations
Type of Supervised by:
No Date of Case Name of Operation Name of Name of
Diagnosis Anesthes Name/Signature of
. Operation No. Patient Performed Surgeon Hospital
ia Qualified C.I.
Pregnancy Uterine 38
weeks, Age of Gestation,
Jesusa
delivered Operatively to Low Cervical Spinal Pangasinan
1 October 9, 2010 251929 Cayabyab Dr. Sheryl Pajarillo Mr. Randel S. Munoz
an alive baby boy Caesarian Section Anesthesia Provincial Hospital
Bautista
Gravida 2 Parity 2
(2002), Repeat CS

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

CERALDE, ANGELITA L. MRS. GLORIA M. ERIVE MR. CRESENCIO C. QUINTO MRS. JODI S. DELA CRUZ MRS. VIRGINIA V. MENDOZA
Name of Student Chief Nurse JR. Dean, College of Nursing
(Signature Over Printed Pangasinan Provincial Clinical Coordinator Qualified Faculty Date Signed :
Name) Hospital Date signed : Pangasinan Provincial Hospital Degree : R.N., M.A.Ed., M.A.N.,
Date Signed : Degree : B.S.N., R.N., Date Signed : Ed.D.
Degree : B.S.N., R.N., M.A.N. Degree : B.S.N., R.N., a) PRC No. : 0042414
M.A.N. a). PRC No. : 0292288 M.A.N. Valid Until : April 29, 2011
a) PRC No. : 0082420 Valid Until : July 18, 2011 a). PRC No. : 0179039 b) PNA No. : 378
Valid Until : December 05, b). PNA No. : 013897 Valid Until : February 22, Valid Until : Lifetime
2010 Valid Until : October 31, 2012 c) ADPCN No. : 190
b) PNA No. : 11972 2010 b). PNA No. : 061503 Valid Until : December 31, 2010
Valid Until : Lifetime Valid Until : October 31,
c) ANSAP No. : 0469 2010
Valid Until : Lifetime
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: CERALDE, ANGELITA L.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): B.S. Information Technology School Graduated From: AMA Computer College Year: 2004
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of
Diagnosis Name of Surgeon Name of Hospital Name/Signature of
. Operation No. Patient Performed Anesthesia
Qualified C.I.
10-93- April Anne Right Medio Lateral Local Dr. Josephine B. Eastern Pangasinan
1 July 2, 2010 Episiorrhaphy Mrs. Rosalie R. Marron
38 Sidoro Episiorrhaphy Anesthesia Guiang District Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

CERALDE, ANGELITA L. MRS. ROSALIA R. MATEO MR. CRESENCIO C. QUINTO MRS. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
Name of Student Assistant Chief Nurse JR. Dean, College of Nursing
(Signature Over Printed Eastern Pangasinan Provincial Clinical Coordinator Qualified Faculty Date Signed :
Name) Hospital Date signed : Eastern Pangasinan Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date signed : Degree : B.S.N., R.N., Provincial Hospital a) PRC No. : 0042414
Degree : R.N., M.A.N. M.A.N. Date Signed : Valid Until : April 29, 2011
a.) PRC No. : 0099313 a). PRC No. : 0292288 Degree : B.S.N., R.N., b) PNA No. : 378
Valid Until : September 14, Valid Until : July 18, 2011 M.A.N. Valid Until : Lifetime
2012 b). PNA No. : 013897 a). PRC No. : 0254320 c) ADPCN No. : 190
b.) PNA No. : 612125 Valid Until : October 31, Valid Until : September 23, Valid Until : December 31, 2010
Valid Until : Lifetime 2010 2012
c.) ANSAP No. : 0491 b). PNA No. : 018456
Valid Until : Lifetime Valid Until : October 31,
2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: CERALDE, ANGELITA L.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): B.S. Information Technology School Graduated From: AMA Computer College Year: 2004
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

III. Actual Deliveries

Time
Supervised by:
No Case Name of of Gender Name of Type of
Diagnosis Age Date of Delivery Name/Signature
. No. Mother Deliver of Baby Hospital Delivery
of Qualified C.I.
y
Pregnancy Uterine Full Term, Eastern
Normal
Cephalic delivered to an alive April Anne Pangasinan Mrs. Rosalie R.
1 238198 19 July 2, 2010 5:15am Female Spontaneous
baby girl Gravida 1 Parity 1 Sidoro Provincial Marron
Delivery
(1001) Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

CERALDE, ANGELITA L.
Name of Student
(Signature Over Printed Name)
MRS. ROSALIA R. MATEO
Assistant Chief Nurse
Eastern Pangasinan
Provincial Hospital
Date signed :
Degree : R.N., M.A.N.
a.) PRC No. : 0099313
Valid Until : September
14, 2012
b.) PNA No. : 612125
Valid Until : Lifetime
c.) ANSAP No. : 0491
Valid Until : Lifetime
MR. CRESENCIO C. QUINTO MRS. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
JR. Qualified Faculty Dean, College of Nursing
Clinical Coordinator Eastern Pangasinan Date Signed :
Date signed : Provincial Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Degree : B.S.N., R.N., Date Signed : a) PRC No. : 0042414
M.A.N. Degree : B.S.N., R.N., Valid Until : April 29, 2011
a). PRC No. : 0292288 M.A.N. b) PNA No. : 378
Valid Until : July 18, 2011 a). PRC No. : 0254320 Valid Until : Lifetime
b). PNA No. : 013897 Valid Until : September c) ADPCN No. : 190
Valid Until : October 31, 23, 2012 Valid Until : December 31, 2010
2010 b). PNA No. : 018456
Valid Until : October 31,
2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: CERALDE, ANGELITA L.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): B.S. Information Technology School Graduated From: AMA Computer College Year: 2004
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

IV. Assisted Deliveries

Time
Supervised by:
No Case Name of of Gender Name of Type of
Diagnosis Age Date of Delivery Name/Signature
. No. Mother Deliver of Baby Hospital Delivery
of Qualified C.I.
y
Pregnancy Uterine Full Term, Eastern
Ruby Normal
09-12- Cephalic delivered to an alive Pangasinan Mrs. Rosalie R.
1 Geronemo 39 June 19, 2010 3:11am Female Spontaneous
79 baby girl Gravida 1 Parity 1 Provincial Marron
Bodoy Delivery
(1001) Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

CERALDE, ANGELITA L.
Name of Student
(Signature Over Printed Name)
MRS. ROSALIA R. MATEO
Assistant Chief Nurse
Eastern Pangasinan
Provincial Hospital
Date signed :
Degree : R.N., M.A.N.
a.) PRC No. : 0099313
Valid Until : September
14, 2012
b.) PNA No. : 612125
Valid Until : Lifetime
c.) ANSAP No. : 0491
Valid Until : Lifetime
MR. CRESENCIO C. QUINTO MRS. JOCELYN G. MACARAEG MRS. VIRGINIA V. MENDOZA
JR. Qualified Faculty Dean, College of Nursing
Clinical Coordinator Eastern Pangasinan Date Signed :
Date signed : Provincial Hospital Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Degree : B.S.N., R.N., Date Signed : a) PRC No. : 0042414
M.A.N. Degree : B.S.N., R.N., Valid Until : April 29, 2011
a). PRC No. : 0292288 M.A.N. b) PNA No. : 378
Valid Until : July 18, 2011 a). PRC No. : 0254320 Valid Until : Lifetime
b). PNA No. : 013897 Valid Until : September c) ADPCN No. : 190
Valid Until : October 31, 23, 2012 Valid Until : December 31, 2010
2010 b). PNA No. : 018456
Valid Until : October 31,
2010
LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: CERALDE, ANGELITA L.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): B.S. Information Technology School Graduated From: AMA Computer College Year: 2004
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

V. Cord Dressing
Supervised by:
No Date Gender of
Case No. Name of Baby Name of Mother Age Name of Hospital Name &Signature of
. Performed Baby
Qualified C.I.
Pangasinan Provincial
1 244892 August 28, 2010 Baby Girl Zarate Female Aurora T. Zarate 38 Ms. Maria Jasmin Tugade
Hospital

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

CERALDE, ANGELITA L. MRS. GLORIA M. ERIVE MR. CRESENCIO C. QUINTO MRS. JODI S. DELA CRUZ MRS. VIRGINIA V. MENDOZA
Name of Student Assistant Chief Nurse JR. Dean, College of Nursing
(Signature Over Printed Pangasinan Provincial Clinical Coordinator Qualified Faculty Date Signed :
Name) Hospital Date signed : Pangasinan Provincial Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Date signed : Degree : B.S.N., R.N., Hospital a) PRC No. : 0042414
Degree : R.N., M.A.N. M.A.N. Date Signed : Valid Until : April 29, 2011
a.) PRC No. : 0082420 a). PRC No. : 0292288 Degree : B.S.N., R.N., b) PNA No. : 378
Valid Until : December 5, Valid Until : July 18, 2011 M.A.N. Valid Until : Lifetime
2010 b). PNA No. : 013897 a). PRC No. : 0179039 c) ADPCN No. : 190
b.) PNA No. : 11972 Valid Until : October 31, Valid Until : February 22, Valid Until : December 31, 2010
Valid Until : Lifetime 2010 2012
c.) ANSAP No. : 0469 b). PNA No. : 061503
Valid Until : Lifetime Valid Until : October 31,
2010
 LYCEUM-NORTHWESTERN UNIVERSITY
College of Nursing
As adapted from the form of PRC

Prepared by: CERALDE, ANGELITA L.

Accreditation Level: (if any) Not Applicable Year Granted: Not Applicable
Date School/Program was Recognized: June 14, 1982 Number: GR No. 087 Year: Series 1982
First Course (if any): B.S. Information Technology School Graduated From: AMA Computer College Year: 2004
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011

II. Minor Operations

Supervised by:
No Date of Case Name of Operation Type of
Diagnosis Name of Surgeon Name of Hospital Name/Signature of
. Operation No. Patient Performed Anesthesia
Qualified C.I.
Jennilyn Right Medio Lateral Local Pangasinan Ms. Maria Jasmin
1 July 17, 2010 224270 Episiorrhaphy Dr. Araceli Callao
Resquid Episiorrhaphy Anesthesia Provincial Hospital Tugade
Abortion Incomplete 18 Manual
Theresa P. Dr. Evelyn Pangasinan Ms. Maria Jasmin
2 July 29, 2010 240790 weeks Age Of Gestations Vacuum
Cerezo Angeles Provincial Hospital Tugade
Gravida 2 Parity 1 (2001) Aspiration

Prepared by: Concurred by: Noted by: Supervised by: Approved by:

CERALDE, ANGELITA L. MRS. GLORIA M. ERIVE MR. CRESENCIO C. QUINTO MRS. JODI S. DELA CRUZ MRS. VIRGINIA V. MENDOZA
Name of Student Assistant Chief Nurse JR. Dean, College of Nursing
(Signature Over Printed Pangasinan Provincial Hospital Clinical Coordinator Qualified Faculty Date Signed :
Name) Date signed : Date signed : Pangasinan Provincial Degree : R.N., M.A.Ed., M.A.N., Ed.D.
Degree : R.N., M.A.N. Degree : B.S.N., R.N., Hospital a) PRC No. : 0042414
a.) PRC No. : 0082420 M.A.N. Date Signed : Valid Until : April 29, 2011
Valid Until : December 5, a). PRC No. : 0292288 Degree : B.S.N., R.N., b) PNA No. : 378
2010 Valid Until : July 18, 2011 M.A.N. Valid Until : Lifetime
b.) PNA No. : 11972 b). PNA No. : 013897 a). PRC No. : 0179039 c) ADPCN No. : 190
Valid Until : Lifetime Valid Until : October 31, Valid Until : February 22, Valid Until : December 31, 2010
c.) ANSAP No. : 0469 2010 2012
Valid Until : Lifetime b). PNA No. : 061503
Valid Until : October 31,
2010