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Republic of the Philippines

Professional Regulation Commission
Manila

Name of Student: ________________________________________________________________

Name & Address of School: UNIVERSITY OF SAN JOSE RECOLETOS, COLLEGE OF NURSING, MAGALLANES ST., CEBU CITY /
Accreditation Level: (if any) FULL GOVERNMENT RECOGNITION Year Granted 2008 /
Date School/Program was Recognized: SY 2007 – 2008____________________________ ______ Number 024 Year 2008__________________________
First Course (if any): (applicable for second courser only)_________________________________ School Graduated From: (applicable for second courser only) Year: (applicable for second courser only)
Year of Admission in the Bachelor of Science in Nursing Program: 2006 /
Year Graduated (BSN program): 2010 __________________________________________________________________________________________________________________________

III. Actual Deliveries

No Case Diagnosis Name of Patient Age Date of Time of Gender of Name of Type of Supervised by: Signature over Signature over
Printed Name of Printed Name of
. No. Delivery Delivery Baby Hospital Delivery Name & STAFF NURSE NURSE SUPERVISOR
Signature of (This column is (This column is
Qualified C. I. intended for intended for
validation of cases. validation of cases.
(middle name is Omit this column Omit this column
necessary) when making the when making the
final form. ) final form. )

Prepared by:

__________________________________
Name of Student
Supervised by: Noted by: Concurred by: Approved by:
MR. GLENN M. GAMALIER MS. AUDREY D. VERANO __________________________ MRS. LUZ L. BORROMEO
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed : ________________ Date Signed : Date Signed : Date Signed : ___________________
Degree : BSN., RN., MAN Degree : BSN., RN., MAN Degree : _________________ Degree : BSN., RN., MN.
a.) PRC No : 0343647 a.) PRC No. : 0177666 a.) PRC No. : _________________ a.) PRC No. : 0061246_________
Valid until : DECEMBER 31, 2009 Valid until : AUGUST 19, 2009 Valid until : _________________ Valid until : JULY 18, 2011
b. PNA No. : ________________ b.) PNA No. : 018182 b.) PNA No. : _________________ b.) PNA No. : 10890
Valid until : Valid until : LIFETIME Valid until : _________________ Valid until : LIFETIME
c.) ANSAP No. : _________________ c.) ADPCN No. : 079
Valid until : _________________ Valid until : DECEMBER 31, 2010

I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
_______________________________
Signature of Applicant

Subscribed and sworn to before me _______ day of ____________________ 20______, ________________________, Philippines.

NOTARY PUBLIC