Prc Form ( Minor Operation)

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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): (should be filled up by second coursers only)_____________________________School Graduated From: (should be filled up by second coursers only) Year: (should be filled up by second coursers only)

Year of Admission in the Bachelor of Science in Nursing Program: 2006 ______________________________________________________________________________________________________________ Year Graduated (BSN program): 2010 __________________________________________________________________________________________________________________________________________

No.

Date of Operation

Case No.

Name of Patient

Diagnosis

I. Minor Operations Operation Performed

Type of Anesthesia

Name of Surgeon

Name of Hospital

Name of O.R. Scrub Nurse

Signature of O.R. Scrub Nurse

Signature over Printed Name of Clinical Instructor

1. 2. 3.

Prepared by: ______________________________ Name of Student Supervised by: MR. EMILIANO IAN B. SUSON II

Noted by: MRS. MARIBEC V. DELDA

Concurred by: ____________________

Approved by: MRS. LUZ L. BORROMEO

Signature over printed name of Faculty Date Signed:_________________________ Degree :BSN., RN., MAN a.) PRC No :0321033 Valid until: :NOVEMBER 18, 2009 b. PNA No. :_______________ Valid until :_______________

Signature over printed name of Clinical Coordinator Date Signed:_____________________ Degree :BSN., RN., MAN a.) PRC No. :80543 Valid until :APRIL 12, 2011 b.) PNA No. :16018 Valid until :LIFETIME

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

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