University Of St.

La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: Gargar, Larry Jun Sumbi First Course (If any) : NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

I. MAJOR SCRUBS
Type of
Time Time Date of
No. Case No. Name of Patient Operation Performed Anesthesi
Started Ended Operation
a
3 01:25 PM 02:50 PM 07-20-10 1042218 Canson, Aileen Cleft Lip Repair General

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

Larry Jun S. Gargar Leo G. Lozana, RN Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN
Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: RN Degree: RN, MN Degree: RN, MN
Place: a) PRC No: 0351138 a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: 10-05-13 Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until: 10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

Bacolod Our Lady of Mercy Specialty Hospital
 ty Of St. La Salle
ge of Nursing
enue, Bacolod City 6100
l. #: 434-4010

NA Year: NA
NA
Year of Admission in the BSN Program: 2007
Year Graduated from the BSN Program: 2011

MAJOR SCRUBS
Name of Surgeon Name of Hospital

Dr. Jesus Paltriguera BOLMSH

Concurred by:

Josephine L. de la Serna, RN, MN Edelina I. Javellana, RN, MAN

Dean Chief Nurse
Date Signed:
RN, MN Degree: RN,MAN
0037515 a) PRC No: 0140661
06-03-14 Valid Until: 04-05-13
10408 b) PNA No: 055512
Lifetime Valid Until: 10-31-11

y of Mercy Specialty Hospital

 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student:
Gargar, Larry Jun Sumbi First Course (If any) : NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program
Year Graduated from the BSN Program

II. MINOR SCRUBS

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

1 09:52 AM 09:55 AM 05-29-10 10-434 Cagayan, Jerec Circumcision Local

2 11:10 AM 11:19 AM 05-29-10 10-456 Longno, Joshua Circumcision Local

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

Larry Jun S. Gargar Mariles L. Ruiz, RN, MAN Jean E. Javier, RN, MN Josephine L. de la Serna, RN,
Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: RN, MAN Degree: RN, MN Degree: RN, MN
Place: a) PRC No: 0209363 a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: 12-17-11 Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: 055333 b) PNA No: 039802 b) PNA No: 10408
Valid Until: 10-31-11 Valid Until: 10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

University of St La Salle Clinic
y Of St. La Salle
e of Nursing
ue, Bacolod City 6100
#: 434-4010

NA Year: NA
NA
Year of Admission in the BSN Program: 2007
Year Graduated from the BSN Program: 2011

NOR SCRUBS
Name of Surgeon Name of Hospital

Dr. Michael Baldivinos USLS Clinic

Dr. Leonilo del Carmen USLS Clinic

Concurred by:

Josephine L. de la Serna, RN, MN Pacita Caroline J. Tan, RN

Dean Clinic Nurse
Date Signed:
RN, MN Degree: RN
0037515 a) PRC No: 0170059
06-03-14 Valid Until: 07-06-11
10408 b) PNA No: 055520
Lifetime Valid Until: 10-31-11

f St La Salle Clinic
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student:
Gargar, Larry Jun Sumbi First Course (If any) : NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

III. ACTUAL DELIVERIES

Gender of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Time of Delivery
Baby

1 01173339 PUFT Oreta, Elisa 36 05-27-10 10:35 AM M

2 01177758 PUFT Fernandez, Babylin 28 06-25-10 12:56 AM M

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

Larry Jun S. Gargar Ellen P. Cartagena RN, MN Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN
Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: RN,MN Degree: RN, MN Degree: RN, MN
Place: a) PRC No: 0212751 a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: 10-24-11 Valid Until:10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until:10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

NA Year: NA
NA
e BSN Program: 2007
e BSN Program: 2011

Name of Hospital Type of Delivery

CLMMRH NSVD

CLMMRH NSVD

Concurred by:

Joreslyn P. Bala-an, RN, MA

la Serna, RN, MN
Ed., MN
ean Chief Nurse
Date Signed:
RN, MN Degree: RN, MA Ed., MN
0037515 a) PRC No: 0091019
06-03-14 Valid Until:
05-24-11
10408 b) PNA No: 03879
Lifetime Valid Until:
Lifetime
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student:
Gargar, Larry Jun Sumbi First Course (If any) : NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program:
Year Graduated from the BSN Program:

IV. ASSISTED DELIVERIES

No. Case No. Diagnosis Name of Mother Age Date of Delivery Time of Delivery Gender of Baby Name of H

1 01173223 PUFT Deniega, Riza 18 05-26-10 08:41 AM F CLMM

2 01173437 PUFT Guevarra, Ruth 24 06-27-10 01:02 PM M CLMM

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

Larry Jun S. Gargar Ellen P. Cartagena RN, MN Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN
Examinee Clinical Instructor Clinical Supervisor Dean
CTC Number: Date Signed: Date Signed: Date Signed:
Date: Degree: RN,MN Degree: RN, MN Degree: RN, MN
Place: a) PRC No: 0212751 a) PRC No: 0087213 a) PRC No: 0037515
Valid Until: 10-24-11 Valid Until: 10-06-12 Valid Until: 06-03-14
b) PNA No: b) PNA No: 039802 b) PNA No: 10408
Valid Until: Valid Until: 10-31-11 Valid Until: Lifetime

*(Complete Name of Hospital)

 Year: NA

2007
2011

Name of Hospital Type of Delivery

CLMMRH NSVD

CLMMRH NSVD

Concurred by:

Joreslyn P. Bala-an, RN, MA Ed.,

MN
Chief Nurse
Date Signed:
Degree: RN, MA Ed., MN
a) PRC No: 0091019
Valid Until:05-24-11
b) PNA No: 03879
Valid Until:Lifetime
 University Of St. La Salle
College of Nursing
La Salle Avenue, Bacolod City 6100
Tel. #: 434-4010

Name of Student: Gargar, Larry Jun Sumbi First Course (If any) : NA Year: NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program: 2007
Year Graduated from the BSN Program: 2011

V. CORD DRESSING
No. Case No. Date Performed Time of Delivery Gender of Baby Name of Mother Age Name of Hospital

1 32826 07-09-09 M Jalipa, Vivian 39 BOLMSH

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

Larry Jun S. Gargar Arlene T. Conlu, RN, MN Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN Edelina I. Javellana, RN, MAN
Examinee Clinical Instructor Clinical Supervisor Dean Chief Nurse
CTC Number: Date Signed: Date Signed: Date Signed: Date Signed:
Date: Degree: RN,MN Degree: RN, MN Degree: RN, MN Degree: RN,MAN
Place: a) PRC No: 0284069 a) PRC No: 0087213 a) PRC No: 0037515 a) PRC No: 0140661
Valid Until: 01-11-12 Valid Until: 10-06-12 Valid Until: 06-03-14 Valid Until:04-05-13
b) PNA No: b) PNA No: 039802 b) PNA No: 10408 b) PNA No: 055512
Valid Until: Valid Until: 10-31-11 Valid Until: Lifetime Valid Until:
10-31-11

*(Complete Name of Hospital)

Bacolod Our Lady of Mercy Specialty Hospital
rsity Of St. La Salle
llege of Nursing
Avenue, Bacolod City 6100
Tel. #: 434-4010

CORD DRESSING
Name of Hospital

BOLMSH

Edelina I. Javellana, RN, MAN

Chief Nurse

RN,MAN
0140661
04-05-13
055512
10-31-11

y of Mercy Specialty Hospital