UNCIANO COLLEGES, INC.

Circumferential Road, Antipolo City

I. Major Operations
Signature of
Date of Name of Qualified
No. Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Qualified Clinical
Operation Clinical Instructor
Instructor
1
2
3
4
5

Prepared by:

Name of Student:
Name & Address of School:
Accreditation Level (if any): Year Granted:
Date School / Program was Recognized: GR (R-IV) Number 004 S. 1992
First Course (if any): School Graduated from: Year Graduated:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Noted by: Concurred by: Approved by:

FILOMENA I. RAMOS NANCY D. SANCHEZ MINLUVISA B. CARAG

Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Designated Signatory Signature over printed name of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: BSN, RN, MAN Degree: Degree: BSN, RN, MAN Degree: BSN, RN, MN, MAEd, PD.
a) PRC No: 0049375 a) PRC No.: a) PRC No.: 0228073 a) PRC No: 0025934
Valid Until: 07-05-2010 Valid Until: Valid Until: 12-20-2009 Valid Until: 03-24-2010
b) PNA No: 26897 b) PNA No.: b) PNA No.: 26896 b) PNA No: 26874
Valid Until: 12-31-2007 Valid Until: Valid Until: 12-31-2007 Valid Until: 12-31-2007
c) ADPCN No: 25071
Valid Until: 05-2007
 UNCIANO COLLEGES, INC.
Circumferential Road, Antipolo City

II. Minor Operations

No. Date of Case No. Name of Patient Diagnosis Operation Performed Type of Name of Surgeon Name of Hospital Name of Qualified Signature of Qualified
Operation Anesthesia Clinical Instructor Clinical Instructor
1
2
3
4
5

Prepared by:

Name of Student:
Name & Address of School:
Accreditation Level (if any): Year Granted:
Date School / Program was Recognized: GR (R-IV) Number 004 S. 1992
First Course (if any): School Graduated from: Year Graduated:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Noted by: Concurred by: Approved by:

FILOMENA I. RAMOS NANCY D. SANCHEZ MINLUVISA B. CARAG

Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Designated Signatory Signature over printed name of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: BSN, RN, MAN Degree: Degree: BSN, RN, MAN Degree: BSN, RN, MN, MAEd, PD.
a) PRC No: 0049375 a) PRC No.: a) PRC No.: 0228073 a) PRC No: 0025934
Valid Until: 07-05-2010 Valid Until: Valid Until: 12-20-2009 Valid Until: 03-24-2010
b) PNA No: 26897 b) PNA No.: b) PNA No.: 26896 b) PNA No: 26874
Valid Until: 12-31-2007 Valid Until: Valid Until: 12-31-2007 Valid Until: 12-31-2007
c) ADPCN No: 25071
Valid Until: 05-2007
 UNCIANO COLLEGES, INC.
Circumferential Road, Antipolo City

III. Actual Deliveries

No. Case Diagnosis Name of Mother Age Date of Time of Gender of Name of Hospital Type of Delivery Supervised by: Name &
No. Delivery Delivery Baby Signature of Qualified C.I.
1
2
3
4
5

Prepared by:

Name of Student:
Name & Address of School:
Accreditation Level (if any): Year Granted:
Date School / Program was Recognized: GR (R-IV) Number 004 S. 1992
First Course (if any): School Graduated from: Year Graduated:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Noted by: Concurred by: Approved by:

FILOMENA I. RAMOS NANCY D. SANCHEZ MINLUVISA B. CARAG

Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Designated Signatory Signature over printed name of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: BSN, RN, MAN Degree: Degree: BSN, RN, MAN Degree: BSN, RN, MN, MAEd, PD.
a) PRC No: 0049375 a) PRC No.: a) PRC No.: 0228073 a) PRC No: 0025934
Valid Until: 07-05-2010 Valid Until: Valid Until: 12-20-2009 Valid Until: 03-24-2010
b) PNA No: 26897 b) PNA No.: b) PNA No.: 26896 b) PNA No: 26874
Valid Until: 12-31-2007 Valid Until: Valid Until: 12-31-2007 Valid Until: 12-31-2007
c) ADPCN No: 25071
Valid Until: 05-2007
 UNCIANO COLLEGES, INC.
Circumferential Road, Antipolo City

IV. Deliveries Assisted

No. Case Diagnosis Name of Patient Age Date of Time of Gender of Name of Hospital Type of Delivery Supervised by:
No. Delivery Delivery Baby Name & Signature of
Qualified C.I.
1
2
3
4
5

Prepared by:

Name of Student:
Name & Address of School:
Accreditation Level (if any): Year Granted:
Date School / Program was Recognized: GR (R-IV) Number 004 S. 1992
First Course (if any): School Graduated from: Year Graduated:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Noted by: Concurred by: Approved by:

FILOMENA I. RAMOS NANCY D. SANCHEZ MINLUVISA B. CARAG

Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Designated Signatory Signature over printed name of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: BSN, RN, MAN Degree: Degree: BSN, RN, MAN Degree: BSN, RN, MN, MAEd, PD.
a) PRC No: 0049375 a) PRC No.: a) PRC No.: 0228073 a) PRC No: 0025934
Valid Until: 07-05-2010 Valid Until: Valid Until: 12-20-2009 Valid Until: 03-24-2010
b) PNA No: 26897 b) PNA No.: b) PNA No.: 26896 b) PNA No: 26874
Valid Until: 12-31-2007 Valid Until: Valid Until: 12-31-2007 Valid Until: 12-31-2007
c) ADPCN No: 25071
Valid Until: 05-2007
 UNCIANO COLLEGES, INC.
Circumferential Road, Antipolo City

V. Cord Dressing
No. Case No. Date Performed Name of Baby Gender of Name of Mother Age Name of Hospital Supervised by:
Baby Name & Signature of
Qualified C.I.
1
2
3
4
5

Prepared by:

Name of Student:
Name & Address of School:
Accreditation Level (if any): Year Granted:
Date School / Program was Recognized: GR (R-IV) Number 004 S. 1992
First Course (if any): School Graduated from: Year Graduated:
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

Noted by: Concurred by: Approved by:

FILOMENA I. RAMOS NANCY D. SANCHEZ MINLUVISA B. CARAG

Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Designated Signatory Signature over printed name of Dean
Date Signed: Date Signed: Date Signed: Date Signed:
Degree: BSN, RN, MAN Degree: Degree: BSN, RN, MAN Degree: BSN, RN, MN, MAEd, PD.
a) PRC No: 0049375 a) PRC No.: a) PRC No.: 0228073 a) PRC No: 0025934
Valid Until: 07-05-2010 Valid Until: Valid Until: 12-20-2009 Valid Until: 03-24-2010
b) PNA No: 26897 b) PNA No.: b) PNA No.: 26896 b) PNA No: 26874
Valid Until: 12-31-2007 Valid Until: Valid Until: 12-31-2007 Valid Until: 12-31-2007
c) ADPCN No: 25071
Valid Until: 05-2007