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Blank PRC Form Actual Delivery

This document contains information about a nursing student's education and clinical experience. It includes the student's name, the name and address of their school, the accreditation level and date the school/program was recognized. It also lists the student's first course, the school they graduated from, and the year they were admitted and graduated from the Bachelor of Science in Nursing program. The document concludes with a section to record the student's actual deliveries as part of their clinical experience, including case number, diagnosis, age of the mother, date and time of delivery, gender of the baby, name of the hospital, and signature of the clinical supervisor.

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marengbib
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233 views1 page

Blank PRC Form Actual Delivery

This document contains information about a nursing student's education and clinical experience. It includes the student's name, the name and address of their school, the accreditation level and date the school/program was recognized. It also lists the student's first course, the school they graduated from, and the year they were admitted and graduated from the Bachelor of Science in Nursing program. The document concludes with a section to record the student's actual deliveries as part of their clinical experience, including case number, diagnosis, age of the mother, date and time of delivery, gender of the baby, name of the hospital, and signature of the clinical supervisor.

Uploaded by

marengbib
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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COLLEGE OF THE HOLY SPIRIT OF TARLAC

COLLEGE OF NURSING

Name of Student:
___________________________________________________________________________________________________________________________________________________________

Name and 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


Name of Date of Time of Gender Name of Supervised by: Signature
No. Case No. Diagnosis Age Type of Delivery
Mother Delivery Delivery of Baby Hospital of OR/DR Supervisor

1.

2.

3.

Noted By:

_______________________________________ a.) PRC NO: _____________________________


Signature over printed name of Chief Nurse Valid Until: ___________________________ __________________________________
b.) PNA NO: _____________________________ Signature over printed name of Dean
Date Signed: ____________________________ Valid Until: ___________________________
Degree:_________________________________ Date Signed: _______________________
a.) PRC NO: ____________________________ Degree:___________________________
Valid Until: ___________________________ _______________________________________ a.) PRC NO: ________________________
b.) PNA NO: _____________________________ Signature over printed name of Clinical Coordinator Valid Until: ______________________
Valid Until: ___________________________ b.) PNA NO: ________________________
Date Signed: ____________________________ Valid Until: ______________________
Degree:_________________________________ c.) ADPCN NO: _____________________
_______________________________________ a.) PRC NO: _____________________________ Valid Until:
Signature over printed name of Chief Nurse Valid Until: ___________________________
b.) PNA NO: _____________________________
Date Signed: ____________________________ Valid Until: ___________________________
Degree:_________________________________

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