University Of St.

La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: First Course (If any) : NA

Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

I. MAJOR SCRUBS
Type of
Time Time Date of
No. Case No. Name of Patient Operation Performed Anesthesi
Started Ended Operation
a
1

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

Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN

Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: Degree: RN, MN Degree: RN, MN
Place: a) PRC No: a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until: 10-31-11 Valid Until: Lifetime
*(Complete Name of Hospital)
 ty Of St. La Salle
ge of Nursing
enue, Bacolod City 6100
l. #: 434-4010

NA Year: NA
NA
Year of Admission in the BSN Program: 2007
Year Graduated from the BSN Program: 2011

MAJOR SCRUBS
Name of Surgeon Name of Hospital

Concurred by:

Josephine L. de la Serna, RN, MN

Dean Chief Nurse
Date Signed:
RN, MN Degree:
0037515 a) PRC No:
06-03-14 Valid Until:
10408 b) PNA No:
Lifetime Valid Until:
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: First Course (If any) : NA

Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program
Year Graduated from the BSN Program

II. MINOR SCRUBS

Date of Type of
No. Time Started Time Ended Case No. Name of Patient Operation Performed
Operation Anesthesia

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

Jean E. Javier, RN, MN Josephine L. de la Serna, RN,

Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: Degree: RN, MN Degree: RN, MN
Place: a) PRC No: a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until: 10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

y Of St. La Salle
e of Nursing
ue, Bacolod City 6100
#: 434-4010

NA Year: NA
NA
Year of Admission in the BSN Program: 2007
Year Graduated from the BSN Program: 2011

NOR SCRUBS
Name of Surgeon Name of Hospital

Concurred by:

Josephine L. de la Serna, RN, MN

Dean Chief Nurse
Date Signed:
RN, MN Degree:
0037515 a) PRC No:
06-03-14 Valid Until:
10408 b) PNA No:
Lifetime Valid Until:
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: First Course (If any) : NA

Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

III. ACTUAL DELIVERIES

Gender of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Time of Delivery
Baby

1 PUFT

2 PUFT

3 PUFT

4 PUFT

5 PUFT

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

Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN

Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: Degree: RN, MN Degree: RN, MN
Place: a) PRC No: a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: Valid Until:10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until:10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

NA Year: NA
NA
e BSN Program: 2007
e BSN Program: 2011

Name of Hospital Type of Delivery

Concurred by:

la Serna, RN, MN
ean Chief Nurse
Date Signed:
RN, MN Degree:
0037515 a) PRC No:
06-03-14 Valid Until:
10408 b) PNA No:
Lifetime Valid Until:
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: First Course (If any) : NA

Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

IV. ASSISTED DELIVERIES

No. Case No. Diagnosis Name of Mother Age Date of Delivery Time of Delivery Gender of Baby Name of H

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

Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN

Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: Degree: RN, MN Degree: RN, MN
Place: a) PRC No: a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until: 10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

 Year: NA

2007
2011

Name of Hospital Type of Delivery

Concurred by:

Chief Nurse
Date Signed:
Degree:
a) PRC No:
Valid Until:
b) PNA No:
Valid Until:
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: Gargar Larry Jun Sumbi First Course (If any) : NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

V. CORD DRESSING
No. Case No. Date Performed Time of Delivery Gender of Baby Name of Mother Age

2 01152702 01-15-10 M Tana, Riza 31

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

Larry Jun S. Gargar Barbara Ruth Myla F. Lim, RN, MN Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN
Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: RN, MN Degree: RN, MN Degree: RN, MN
Place: a) PRC No: 0284197 a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: 10-20-11 Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: 055349 b) PNA No: 039802 b) PNA No: 10408
Valid Until: 10-31-11 Valid Until: 10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

rsity Of St. La Salle
llege of Nursing
Avenue, Bacolod City 6100
Tel. #: 434-4010

NA Year: NA
NA
Year of Admission in the BSN Program: 2007
Year Graduated from the BSN Program: 2011

. CORD DRESSING
Age Name of Hospital

31 CLMMRH

Concurred by:

Joreslyn P. Bala-an, RN, MA

Josephine L. de la Serna, RN, MN
Ed., MN
Dean Chief Nurse
Date Signed:
RN, MN Degree: RN, MA Ed., MN
0037515 a) PRC No: 0091019
06-03-14 Valid Until:05-24-11
10408 b) PNA No: 03879
Lifetime Valid Until:
Lifetime