Prc-assisted Delivery 2010

Page 2 of 2 Republic of the Philippines Professional Regulation Commission Manila Name of Student: ________________________________________________________________ Name & Address of School: UNIVERSITY OF SAN JOSE RECOLETOS, COLLEGE OF NURSING, MAGALLANES ST., CEBU CITY / Accreditation Level: (if any) FULL GOVERNMENT RECOGNITION Year Granted 2008 / Date School/Program was Recognized: SY 2007 – 2008____________________________ ______ Number 024 Year 2008__________________________ First Course (if any): (applicable for second courser only)_________________________________ School Graduated From: (applicable for second courser only) Year: (applicable for second courser only) Year of Admission in the Bachelor of Science in Nursing Program: 2006 / Year Graduated (BSN program): 2010 __________________________________________________________________________________________________________________________

No .

Case No.

Diagnosis

Name of Patient

Age

IV. Deliveries Assisted Date of Time of Delivery Delivery

Gender of Baby

Name of Hospital

Type of Delivery

Supervised by: Name & Signature of Qualified C. I. (middle name is necessary)

Signature over Printed Name of STAFF NURSE (This column is intended for validation of cases. Omit this column when making the final form. )

Signature over Printed Name of NURSE SUPERVISOR (This column is intended for validation of cases. Omit this column when making the final form. )

Prepared by: __________________________________

Name of Student Supervised by: MR. GLENN M. GAMALIER

Signature over printed name of Faculty Date Signed : ________________ Degree : BSN., RN., MAN a.) PRC No : 0343647 Valid until : DECEMBER 31, 2009 b. PNA No. : ________________ Valid until :

Noted by: MS. AUDREY D. VERANO

Signature over printed name of Clinical Coordinator Date Signed : Degree : BSN., RN., MAN a.) PRC No. : 0177666 Valid until : AUGUST 19, 2009 b.) PNA No. : 018182 Valid until : LIFETIME

Concurred by: __________________________

Signature over printed name of Chief Nurse Date Signed : Degree : _________________ a.) PRC No. : _________________ Valid until : _________________ b.) PNA No. : _________________ Valid until : _________________ c.) ANSAP No. : _________________ Valid until : _________________

Approved by: MRS. LUZ L. BORROMEO

Signature over printed name of Dean Date Signed : ___________________ Degree : BSN., RN., MN. a.) PRC No. : 0061246_________ Valid until : JULY 18, 2011 b.) PNA No. : 10890 Valid until : LIFETIME c.) ADPCN No. : 079 Valid until : DECEMBER 31, 2010

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. _______________________________

Signature of Applicant

Subscribed and sworn to before me _______ day of ____________________ 20______, ________________________, Philippines. NOTARY PUBLIC