OUR LADY OF FATIMA UNIVERSITY

#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

Name of Student: ________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY / #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY
Accreditation Level (if any): PACUCOA LEVEL II_____________________ Year Granted: APRIL 10, 2002____________________________________
Date School/Program was Recognized: April 25, 2001________________ Number: 033 Year: 2001________________
First Course (if any): NOT APPLICABLE_______________ School Graduated From: NOT APPLICABLE____________ Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: JUNE 2006________________________________________________________
Year Graduated (BSN Program): ____________________________________________________________________________________________

I. Major Operations
Date of Case Name of Operation Type of Name of Supervised by Qualified Signature of
No. Diagnosis Name of Surgeon
Operation No. Patient Performed Anesthesia Hospital CI Qualified CI

1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

_______________________________ MARISOL GARCIA- MANIPOL RN, MAN ________________________________ ________________________________ NELIA R. CAPULONG, RN, MAN
Signature over printed Name of Student Signature over printed name of Clinical Signature over printed name of Signature over printed name of Signature over printed name of
Coordinator Chief Nurse Chief Nurse Dean
Supervised by: Date Signed: ___________ Date Signed: ___________ Date Signed: ___________ Date Signed: ____________
Degree: BSN, MAN Degree: _____________________ Degree: _____________________ Degree: BSN, MAN
_______________________________ a.) PRC NO: 0296870 a.) PRC NO:__________________ a.) PRC NO:__________________ a.) PRC NO: 0041904
Signature over printed name of Faculty Valid Until: SEPTEMBER 2012 Valid Until:________________ Valid Until:________________ Valid Until: JULY 31, 2012
Date Signed: _________________ b.) PNA NO: 035591 b.) PNA NO: __________________ b.) PNA NO: __________________ b.) PNA NO: 18698
Degree: ____________________ Valid Until: OCTOBER 31, 2010 Valid Until: ________________ Valid Until: ________________ Valid Until: LIFETIME
a.) PRC NO: ________________ c.) ADPCN NO: 0627
Valid Until: _______________ Valid Until: DECEMBER 2010
b.) PNA NO: _________________
Valid Until: _______________
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: ________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY / #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY
Accreditation Level (if any): PACUCOA LEVEL II_____________________ Year Granted: APRIL 10, 2002____________________________________
Date School/Program was Recognized: April 25, 2001________________ Number: 033 Year: 2001________________
First Course (if any): NOT APPLICABLE_______________ School Graduated From: NOT APPLICABLE____________ Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: JUNE 2006________________________________________________________
Year Graduated (BSN Program): ____________________________________________________________________________________________

II. Minor Operations

Date of Operation Type of Name of Signature of
No. Case No. Name of Patient Diagnosis Name of Surgeon Supervised by Qualified CI
Operation Performed Anesthesia Hospital Qualified CI

1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

_______________________________ MARISOL GARCIA- MANIPOL RN, MAN ________________________________ ________________________________ NELIA R. CAPULONG, RN, MAN
Signature over printed Name of Student Signature over printed name of Clinical Signature over printed name of Signature over printed name of Signature over printed name of Dean
Coordinator Chief Nurse Chief Nurse Date Signed: ____________
Supervised by: Date Signed: ___________ Date Signed: ___________ Date Signed: ___________ Degree: BSN, MAN
Degree: BSN, MAN Degree: _____________________ Degree: _____________________ b.) PRC NO: 0041904
_______________________________ a.) PRC NO: 0296870 a.) PRC NO:__________________ a.) PRC NO:__________________ Valid Until: JULY 31, 2012
Signature over printed name of Faculty Valid Until: SEPTEMBER 2012 Valid Until:________________ Valid Until:________________ b.) PNA NO: 18698
Date Signed: _________________ b.) PNA NO: 035591 b.) PNA NO: __________________ b.) PNA NO: __________________ Valid Until: LIFETIME
Degree: ____________________ Valid Until: OCTOBER 31, 2010 Valid Until: ________________ Valid Until: ________________ c.) ADPCN NO: 0627
b.) PRC NO: ________________ Valid Until: DECEMBER 2010
Valid Until: _______________
b.) PNA NO: _________________
Valid Until: _______________
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: ________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY / #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY
Accreditation Level (if any): PACUCOA LEVEL II_____________________ Year Granted: APRIL 10, 2002____________________________________
Date School/Program was Recognized: April 25, 2001________________ Number: 033 Year: 2001________________
First Course (if any): NOT APPLICABLE_______________ School Graduated From: NOT APPLICABLE____________ Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: JUNE 2006________________________________________________________
Year Graduated (BSN Program): ____________________________________________________________________________________________

III. Actual Deliveries

Supervised by:
Name of Date of Time of Gender of Signature of
No. Case No. Diagnosis Age Name of Hospital Type of Delivery Signature of Qualified
Mother Delivery Delivery Baby Qualified CI
C.I.

1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

_______________________________ MARISOL GARCIA- MANIPOL RN, MAN _______________________________ ________________________________ NELIA R. CAPULONG, RN, MAN
Signature over printed Name of Student Signature over printed name of Clinical Signature over printed name of Signature over printed name of Signature over printed name of
Coordinator Chief Nurse Chief Nurse Dean
Supervised by: Date Signed: ___________ Date Signed: ___________ Date Signed: ___________ Date Signed: ____________
Degree: BSN, MAN Degree: _____________________ Degree: _____________________ Degree: BSN, MAN
_______________________________ a.) PRC NO: 0296870 a.) PRC NO:__________________ a.) PRC NO:__________________ c.) PRC NO: 0041904
Signature over printed name of Faculty Valid Until: SEPTEMBER 2012 Valid Until:________________ Valid Until:________________ Valid Until: JULY 31, 2012
Date Signed: _________________ b.) PNA NO: 035591 b.) PNA NO: __________________ b.) PNA NO: __________________ b.) PNA NO: 18698
Degree: ____________________ Valid Until: OCTOBER 31, 2010 Valid Until: ________________ Valid Until: ________________ Valid Until: LIFETIME
c.) PRC NO: ________________ c.) ADPCN NO: 0627
Valid Until: _______________ Valid Until: DECEMBER 2010
b.) PNA NO: _________________
Valid Until: _______________
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: ________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY / #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY
Accreditation Level (if any): PACUCOA LEVEL II_____________________ Year Granted: APRIL 10, 2002____________________________________
Date School/Program was Recognized: April 25, 2001________________ Number: 033 Year: 2001________________
First Course (if any): NOT APPLICABLE_______________ School Graduated From: NOT APPLICABLE____________ Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: JUNE 2006________________________________________________________
Year Graduated (BSN Program): ____________________________________________________________________________________________

IV. Deliveries Assisted

No Case Name of Date of Time of Gender of Supervised by: Signature Signature of
Diagnosis Age Name of Hospital Type of Delivery
. No. Mother Delivery Delivery Baby of Qualified C.I. Qualified CI

1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

_______________________________ MARISOL GARCIA- MANIPOL RN, MAN NELIA R. CAPULONG, RN, MAN
_______________________________ ________________________________
Signature over printed Name of Student Signature over printed name of Clinical Signature over printed name of Dean
Signature over printed name of Signature over printed name of
Coordinator Date Signed: ____________
Chief Nurse Chief Nurse
Supervised by: Date Signed: ___________ Degree: BSN, MAN
Date Signed: ___________ Date Signed: ___________
Degree: BSN, MAN d.) PRC NO: 0041904
Degree: _____________________ Degree: _____________________
_______________________________ a.) PRC NO: 0296870 Valid Until: JULY 31, 2012
a.) PRC NO:__________________ a.) PRC NO:__________________
Signature over printed name of Faculty Valid Until: SEPTEMBER 2012 b.) PNA NO: 18698
Valid Until:________________ Valid Until:________________
Date Signed: _________________ b.) PNA NO: 035591 Valid Until: LIFETIME
b.) PNA NO: __________________ b.) PNA NO: __________________
Degree: ____________________ Valid Until: OCTOBER 31, 2010 c.) ADPCN NO: 0627
Valid Until: ________________ Valid Until: ________________
d.) PRC NO: ________________ Valid Until: DECEMBER 2010
Valid Until: _______________
b.) PNA NO: _________________
Valid Until: _______________
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: ________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY / #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY
Accreditation Level (if any): PACUCOA LEVEL II_____________________ Year Granted: APRIL 10, 2002____________________________________
Date School/Program was Recognized: April 25, 2001________________ Number: 033 Year: 2001________________
First Course (if any): NOT APPLICABLE_______________ School Graduated From: NOT APPLICABLE____________ Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: JUNE 2006________________________________________________________
Year Graduated (BSN Program): ____________________________________________________________________________________________

V. Cord Dressing
No Case Date Supervised by: Signature of
Name of Baby Gender of Baby Name of Mother Age Name of Hospital Signature of Qualified CI
. No. Performed Qualified C.I.

1.

2.

3.

4.

5.

Prepared by: Approved by:

Noted by: Concurred by: Concurred by:
_______________________________ NELIA R. CAPULONG, RN, MAN
Signature over printed Name of Student MARISOL GARCIA- MANIPOL RN, MAN Signature over printed name of Dean
_______________________________ ________________________________
Signature over printed name of Clinical Date Signed: ____________
Signature over printed name of Signature over printed name of
Supervised by: Coordinator Degree: BSN, MAN
Chief Nurse Chief Nurse
Date Signed: ___________ e.) PRC NO: 0041904
Date Signed: ___________ Date Signed: ___________
_______________________________ Degree: BSN, MAN Valid Until: JULY 31, 2012
Degree: _____________________ Degree: _____________________
Signature over printed name of Faculty a.) PRC NO: 0296870 b.) PNA NO: 18698
a.) PRC NO:__________________ a.) PRC NO:__________________
Date Signed: _________________ Valid Until: SEPTEMBER 2012 Valid Until: LIFETIME
Valid Until:________________ Valid Until:________________
Degree: ____________________ b.) PNA NO: 035591 c.) ADPCN NO: 0627
b.) PNA NO: __________________ b.) PNA NO: __________________
e.) PRC NO: ________________ Valid Until: OCTOBER 31, 2010 Valid Until: DECEMBER 2010
Valid Until: ________________ Valid Until: ________________
Valid Until: _______________
b.) PNA NO: _________________
Valid Until: _______________