JMJ MARIST BROTHERS

NOTRE DAME OF MARBEL UNIVERSITY

COLLEGE OF NURSING
CITY OF KORONADAL

Name of the Student: Romee Renz Catipay Deloso

Name & Address of the School: Notre Dame of Marbel University; Alunan Avenue, Koronadal City, South Cotabato
Accreditation Level (if any): Year granted:

Date School/Program was recognized: Number: Year:

First course (if any): None Scholl granted from: None

Year of admission in the Bachelor of Science in Nursing Program: 2005

Year Graduated (BSN Program): 2009

I. MAJOR OPERATIONS
NAME & SUPERVISED BY: NAME
NO. DATE OF CASE NAME OF DIAGNOSIS OPERATION TYPE OF NAME OF NAME OF SIGNATURE & SIGNATURE OF
OPERATION NUMBER PATIENT PERFORMED ANESTHESIA SURGEON HOSPITAL OF O.R. SCRUB QUALIFIED CLINICAL
NURSE INSTRUCTOR

Noted by: Concurred by: Approved by:

MERNA S. LEBANAN, RN, MAN

Clinical Coordinator Chief Nurse Dean, College 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 until: Valid until:
Prepared by: ROMEE RENZ CATIPAY DELOSO, SN
Name of Student

JMJ MARIST BROTHERS

NOTRE DAME OF MARBEL UNIVERSITY
COLLEGE OF NURSING
CITY OF KORONADAL

Name of the Student: Romee Renz Catipay Deloso

Name & Address of the School: Notre Dame of Marbel University; Alunan Avenue, Koronadal City, South Cotabato
Accreditation Level (if any): Year granted:

Date School/Program was recognized: Number: Year:

First course (if any): None Scholl granted from: None

Year of admission in the Bachelor of Science in Nursing Program: 2005

Year Graduated (BSN Program): 2009

II. MINOR OPERATIONS

NAME & SUPERVISED BY: NAME &
NO. DATE OF CASE NAME OF DIAGNOSIS OPERATION TYPE OF NAME OF NAME OF SIGNATURE SIGNATURE OF
OPERATION NUMBER PATIENT PERFORMED ANESTHESIA SURGEON HOSPITAL OF O.R. SCRUB QUALIFIED CLINICAL
NURSE INSTRUCTOR

Noted by: Concurred by: Approved by:

MERNA S. LEBANAN, RN, MAN

Clinical Coordinator Chief Nurse Dean, College 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 until: Valid until:

Prepared by: ROMEE RENZ CATIPAY DELOSO, SN

Name of Student

JMJ MARIST BROTHERS

NOTRE DAME OF MARBEL UNIVERSITY
COLLEGE OF NURSING
CITY OF KORONADAL

Name of the Student: Romee Renz Catipay Deloso

Name & Address of the School: Notre Dame of Marbel University; Alunan Avenue, Koronadal City, South Cotabato
Accreditation Level (if any): Year granted:

Date School/Program was recognized: Number: Year:

First course (if any): None Scholl granted from: None

Year of admission in the Bachelor of Science in Nursing Program: 2005

Year Graduated (BSN Program): 2009

III. ACTUAL DELIVERIES

NAME & SIGNATURE OF

NO. CASE DIAGNOSIS NAME OF MOTHER AGE DATE OF TIME OF GENDER OF NAME OF HOSPITAL TYPE OF QUALIFIED CLINICAL
NUMBER DELIVERY DELIVERY BABY DELIVERY INSTRUCTOR

Noted by: Concurred by: Approved by:

MERNA S. LEBANAN, RN, MAN

 Clinical Coordinator Chief Nurse Chief Nurse Dean, College of Nursing
Date signed: Date signed: Date signed: Date signed:

Degree: Degree: Degree: Degree:

a) PRC No. a) PRC No. a) PRC No. a) PRC No.

Valid until: Valid until: Valid unit: Valid until:
b) PNA No. b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid unit: Valid until:
c) ADPCN No.
Valid until:
Prepared by: ROMEE RENZ CATIPAY DELOSO, SN
Name of Student

JMJ MARIST BROTHERS

NOTRE DAME OF MARBEL UNIVERSITY
COLLEGE OF NURSING
CITY OF KORONADAL

Name of the Student: Romee Renz Catipay Deloso

Name & Address of the School: Notre Dame of Marbel University; Alunan Avenue, Koronadal City, South Cotabato
Accreditation Level (if any): Year granted:

Date School/Program was recognized: Number: Year:

First course (if any): None Scholl granted from: None

Year of admission in the Bachelor of Science in Nursing Program: 2005

Year Graduated (BSN Program): 2009

IV. DELIVERIES ASSISTED

NAME & SIGNATURE OF
NO. CASE DIAGNOSIS NAME OF AGE DATE OF TIME OF GENDER NAME OF HOSPITAL TYPE OF QUALIFIED CLINICAL
NUMBER MOTHER DELIVERY DELIVERY OF BABY DELIVERY INSTRUCTOR

5
Noted by: Concurred by: Approved by:

MERNA S. LEBANAN, RN, MAN

Clinical Coordinator Chief Nurse Chief Nurse Dean, College of Nursing
Date signed: Date signed: Date signed: Date signed:

Degree: Degree: Degree: Degree:

a) PRC No. a) PRC No. a) PRC No. a) PRC No.

Valid until: Valid until: Valid unit: Valid until:
b) PNA No. b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid unit: Valid until:
c) ADPCN No.
Valid until:
Prepared by: ROMEE RENZ CATIPAY DELOSO, SN
Name of Student

JMJ MARIST BROTHERS

NOTRE DAME OF MARBEL UNIVERSITY
COLLEGE OF NURSING
CITY OF KORONADAL

Name of the Student: Romee Renz Catipay Deloso

Name & Address of the School: Notre Dame of Marbel University; Alunan Avenue, Koronadal City, South Cotabato
Accreditation Level (if any): Year granted:

Date School/Program was recognized: Number: Year:

First course (if any): None Scholl granted from: None

Year of admission in the Bachelor of Science in Nursing Program: 2005

Year Graduated (BSN Program): 2009

V. CORD DRESSING
NAME & SIGNATURE OF
NO. CASE DIAGNOSIS NAME OF AGE DATE OF TIME OF GENDER NAME OF TYPE OF QUALIFIED CLINICAL
NUMBER MOTHER DELIVERY DELIVERY OF BABY HOSPITAL DELIVERY INSTRUCTOR

3
 4

Noted by: Concurred by: Approved by:

MERNA S. LEBANAN, RN, MAN

Clinical Coordinator Chief Nurse Chief Nurse Dean, College of Nursing
Date signed: Date signed: Date signed: Date signed:

Degree: Degree: Degree: Degree:

a) PRC No. a) PRC No. a) PRC No. a) PRC No.

Valid until: Valid until: Valid unit: Valid until:
b) PNA No. b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid unit: Valid until:
c) ADPCN No.
Valid until:
Prepared by: ROMEE RENZ CATIPAY DELOSO, SN
Name of Student