Major

Republic of the Philippines Ramon Magsaysay Technological University (Formerly Ramon Magsaysay Polytechnic College, Western Luzon Agricultural College, Candelaria School of Fisheries) Iba, Zambales

Name of Student: _ Name & Address of School: Ramon Magsaysay Technological University Iba, Zambales Accreditation Level:

Year Granted:

Date School/Program was Recognized:

Number: Resolution N.

First Course (if any): ________________________________________________

School Graduated from: _____________________

Year: _______

Year of Admission in the Bachelor of Sciences in Nursing Program: _______ Year Graduated (BSN Program): 2009

I. Major Operation No.

Date of Operation

Case No.

Name of Patient

Diagnosis

Operation Performed

Type of Anesthesia

Name of Surgeon

Name of Hospital

Name and Signature of O.R Scrub Nurse

Supervised by (Name & Signature of Qualified Clinical Instructor)

1. 2. 3. 4. 5.

Prepared by: __________________________ NAME OF STUDENT Date Signed________________ Degree: BS – Nursing

Noted by::

Concurred by:

CONTESSA M. GABRIEL, RM, RN, MAN Overall Clinical Coordinator Date Signed:________________________ Degree: Master of Arts in Nursing A.) PRC No.: 0326325 Valid Until: June 1, 2011 B.) PNA No.: 30829 Valid Until: Lifetime

ELIZABETH M. MILLORA, RN, MAN LORETO D. ESCOBAR, RN Chief Nurse President Ramon Magsaysay Memorial Hospital Date Signed: _______________ A.) PRC No.: 0163737 Valid Until: May 8, 2011 B.) PNA No.: 17212 Valid Until: Lifetime

C.) ANSAP No. 01727 Valid Until: Lifetime

Approved by: RUBY B. DUAVE, RN Signature over Printed Name of Chief Nurse San Maercelino District Hospital Degree: Date Signed: __________________ A.) PRC No.: 0102383 Valid Until: October 18, 2011 B.) PNA No.: 10981

Valid Until: Lifetime

RENE E. PUDADERA, RN, MAEd, MAN Dean College of Nursing Date Signed _______________________ Degree: Master of Arts in Nursing A.) PRC No.: 0222457 Valid Until: January 2011 B.) PNA No.: 009188 Valid Until: December 2009 C.) ADPCN No. 0706 Valid Until: December 2010