ST. MARY’S COLLEGE OF TAGUM, INC.

Tagum City

Name of Student: __ _____

Name & Address of School:
Accreditation Level (if any): Year Granted
Date School/Program was recognized: Number Year
First Course (if any): School Graduated From Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

I. Major Operations

No. Date of Case Name of Diagnosis Operation Performed Type of Name of Name of Name of O.R. Signature of Supervised by:
Operation No. Patient Anesthesia Surgeon Hospital Scrub Nurse O.R. Scrub Name & Signature
Nurse of Qualified CI

Prepared by:

Signature over printed name of Student

Noted by: Concurred by: Approved by:

__
Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean of Nursing

Date signed: Date Signed: Date Signed:

Degree: Degree: Degree:
a.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid Until:
b.) PNA No: b.) PNA No: b.) PNA No:
Valid until: Valid until: Valid Until:
c.) ANSAP No c.) ADPCN No:
Valid uil: Valid until:
 ST. MARY’S COLLEGE OF TAGUM, INC.
Tagum City

Name of Student: __ _____

Name & Address of School:
Accreditation Level (if any): Year Granted
Date School/Program was recognized: Number Year
First Course (if any): School Graduated From Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

II. Minor Operations

No. Date of Case Name of Diagnosis Operation Performed Type of Name of Name of Name of O.R. Signature of Supervised by:
Operation No. Patient Anesthesia Surgeon Hospital Scrub Nurse O.R. Scrub Name & Signature
Nurse of Qualified CI

Prepared by:

Signature over printed name of Student

Noted by: Concurred by: Approved by:

__
Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean of Nursing

Date signed: Date Signed: Date Signed:

Degree: Degree: Degree:
c.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid Until:
d.) PNA No: b.) PNA No: b.) PNA No:
Valid until: Valid until: Valid Until:
c.) ANSAP No c.) ADPCN No:
Valid until: Valid until:
 ST. MARY’S COLLEGE OF TAGUM, INC.
Tagum City

Name of Student: __ _____

Name & Address of School:
Accreditation Level (if any): Year Granted
Date School/Program was recognized: Number Year
First Course (if any): School Graduated From Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

III. Actual Deliveries

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

Prepared by:

Signature over printed name of Student

Noted by: Concurred by: Approved by:

__
Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean of Nursing

Date signed: Date Signed: Date Signed:

Degree: Degree: Degree:
e.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid Until:
f.) PNA No: b.) PNA No: b.) PNA No:
 Valid until: Valid until: Valid Until:
c.) ANSAP No c.) ADPCN No:
Valid until: Valid until:
Valid until: Valid until: Valid Until:
c.) ANSAP No c.) ADPCN No:
Valid until: Valid until:

ST. MARY’S COLLEGE OF TAGUM, INC.

Tagum City

Name of Student: __ _____

Name & Address of School:
Accreditation Level (if any): Year Granted
Date School/Program was recognized: Number Year
First Course (if any): School Graduated From Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

IV. Deliveries Assisted

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

Prepared by:

Signature over printed name of Student

Noted by: Concurred by: Approved by:

__
Signature over printed name of Clinical Coordinator Signature over Printed name of Chief Nurse Signature over printed name of Dean of Nursing

Date signed: Date Signed: Date Signed:

Degree: Degree: Degree:
 g.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid Until:
h.) PNA No: b.) PNA No: b.) PNA No:
Valid until: Valid until: Valid Until:
c.) ANSAP No c.) ADPCN No:
Valid until: Valid until:

ST. MARY’S COLLEGE OF TAGUM, INC.

Tagum City

Name of Student: __ _____

Name & Address of School:
Accreditation Level (if any): Year Granted
Date School/Program was recognized: Number Year
First Course (if any): School Graduated From Year
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):

V. Cord Dressing

No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital Supervised by: Name &
Signature of Qualified C.I

Prepared by:

Signature over printed name of Student

Noted by: Concurred by: Approved by:

__
Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean of Nursing

Date signed: Date Signed: Date Signed:

Degree: Degree: Degree:
i.) PRC No.: a.) PRC No.: a.) PRC No.:
Valid until: Valid until: Valid Until:
j.) PNA No: b.) PNA No: b.) PNA No:
Valid until: Valid until: Valid Until:
c.) ANSAP No c.) ADPCN No:
Valid until: Valid until: