Prc~ Major Operation

ST. MARY’S COLLEGE

Tagum City Name of Student: Michael Roy B. Rodriguez Name & Address of School: Saint Mary’s College Kilometer 55 National Highway Tagum City Accreditation Level (if any): Year Granted Date School/Program was Recognized: Number First Course (if any): School Graduated From Year Year of Admission in the Bachelor of Science in Nursing Program: Year Graduated (BSN Program):

No .

Date of Operati on

Case No.

Name of Patient

Diagnosis

I. Major Operations Operatio Type of Name of n Anesthe Surgeon Perform sia ed

Name of Hospital

Year

Name of O.R. Scrub Nurse

Signature of OR Scrub Nurse

Supervise d by: Name & Signature of Qualified C.I.

Prepared by: Michael Roy B. Rodriguez Signature over printed name of student Noted by:

Concurred by:

Approved by:

Josefina S. Balote, RN, MN MAN Signature over printed name of Clinical Coordinator Signature over printed name of Dean Date Signed: Degree: Master in Nursing Nursing

Aida C. Hangad, RN, Signature over printed name of Chief Nurse Date Signed: Degree:

Date Signed: Degree: Master of Arts in

a.) PRC No: 0107556 Valid Until: November 06, 2009 September 30, 2009 b.) PNA No: 23753 1 Valid Until: December member

a.) PRC No: Valid Until:

a.) PRC No:

0059664 Valid Until:

b.) PNA No:

b.) PNA No:

11-DN-0015-

Valid Until: c.) ANSAP No: Valid Until:

2008

Valid Until: c.) ADPCN No: Valid Until:

Lifetime 511 December