West Visayas State University

La Paz, Iloilo City

Name of Student: First Course (if any): N/A Year: N/A

Date School/Program was Recognized: April 21, 1977 School Graduated from: N/A
Accreditation Level: Level III AACCUP (2007) Year of Admission in the BSN Program: 2008
Year Graduated from the BSN Program: 2012

I. MAJOR OPERATIONS
No. Time Started Time Ended Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon

Prepared by: Supervised by: Noted by: Approved by:

SHEILA P. BELIRAN, M.A.N. ROSANA GRACE B. BELO, Ed. D.

Associate Dean/Clinical Coordinator OIC - DEAN

Date Signed: _______________ Date Signed: _______________ Date Signed: _______________ Date Signed: _______________
CTC Number: Degree: Bachelor of Science in Nursing Degree: Master of Arts in Nursing Degree: Master in Public Health, Master in
Nursing, Doctor of Education
Date :
Place : Units Earned Beyond BSN:

a)     PRC No. : a) PRC No. : 0277468 a) PRC No. : 0084964

Valid Until: Valid Until: September 4, 2012 Valid Until: October 22, 2012
b)     PNA No. : b) PNA No. : 022997 b) PNA No. : 06-IL-0487-1
Valid Until: Valid Until: October 31, 2010 Valid Until: Life
Visayas State University
La Paz, Iloilo City

Year: N/A

AJOR OPERATIONS
Name of Surgeon Name of Hospital

Concurred by:

Chief Nurse

Date Signed: _______________

Degree:

a)    PRC No. :
Valid Until:
b)     PNA No. :
Valid Until:
 West Visayas State University
La Paz, Iloilo City

Name of Student: First Course (if any): N/A

Date School/Program was Recognized: April 21, 1977 School Graduated from: N/A
Accreditation Level: Level III AACCUP (2007) Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010

I. MAJOR OPERATIONS
No. Time Started Time Ended Date of Operation Case No. Name of Patient Operation Performed

Prepared by: Supervised by: Noted by: Approved by:

SHEILA P. BELIRAN, M.A.N. ROSANA GRACE B. BE

Associate Dean/Clinical Coordinator OIC - DEAN

Date Signed: _______________ Date Signed: _______________ Date Signed: _______________ Date Signed: _________
CTC Number: Degree: Bachelor of Science in Nursing Degree: Master of Arts in Nursing Degree: Master in Public
Nursing, Doctor of Educa
Date :
Place : Units Earned Beyond BSN:

a)     PRC No. : a) PRC No. : 0277468 a) PRC No. : 0084964

Valid Until: Valid Until: September 4, 2012 Valid Until: October
b)     PNA No. : b) PNA No. : 022997 b) PNA No. : 06-IL-04
Valid Until: Valid Until: October 31, 2010 Valid Until: Life
ayas State University
Paz, Iloilo City

Year: N/A

OR OPERATIONS
Type of Anesthesia Name of Surgeon Name of Hospital

Concurred by:

ROSANA GRACE B. BELO, Ed. D.

Chief Nurse

Date Signed: _______________ Date Signed: _______________

Degree: Master in Public Health, Master in Degree:
Nursing, Doctor of Education

a) PRC No. : 0084964 a)    PRC No. :

Valid Until: October 22, 2012 Valid Until:
b) PNA No. : 06-IL-0487-1 b)     PNA No. :
Valid Until: Life Valid Until: Life
 West Visayas State University
La Paz, Iloilo City

Name of Student: First Course (if any): N/A Year: N/A

Date School/Program was Recognized: April 21, 1977 School Graduated from: N/A
Accreditation Level: Level III AACCUP (2007) Year of Admission in the BSN Program: 2008
Year Graduated from the BSN Program: 2012

I. MAJOR OPERATIONS

No. Time Started Time Ended Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon

Prepared by: Supervised by: Noted by: Approved by:

SHEILA P. BELIRAN, M.A.N. ROSANA GRACE B. BELO, Ed. D.

Associate Dean/Clinical Coordinator OIC - DEAN

Date Signed: _______________ Date Signed: _______________ Date Signed: _______________ Date Signed: _______________
CTC Number: Degree: Bachelor of Science in Nursing Degree: Master of Arts in Nursing Degree: Master in Public Health, Master in
Nursing, Doctor of Education
Date :
Place : Units Earned Beyond BSN:

a)     PRC No. : a) PRC No. : 0277468 a) PRC No. : 0084964

Valid Until: Valid Until: September 4, 2012 Valid Until: October 22, 2012
b)     PNA No. : b) PNA No. : 022997 b) PNA No. : 06-IL-0487-1
Valid Until: Valid Until: October 31, 2010 Valid Until: Life
 isayas State University
La Paz, Iloilo City

Year: N/A

AJOR OPERATIONS

Name of Surgeon Name of Hospital

Concurred by:

Chief Nurse

Date Signed: _______________

Degree:

a)    PRC No. :
Valid Until:
b)     PNA No. :
Valid Until: