FAMILY CLINIC COLLEGES INC.

1452 A.H. Lacson St., Sampaloc, Manila, Philippine

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):_____________________________________________________________________________________________________

I. Major Operations
Signature of
Date of Name of Operation Name of Name of Name of O.R.
No. Case No. Diagnosis Type of Anesthesia O.R. Scrub
Operation Patient Performed Surgeon Hospital Scrub Nurse
Nurse

1.

2.

3.

4.

5.

Noted by:

__________________________________ __________________________________ ___________________________________ ______________________________

Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief
Nurse Nurse Nurse Nurse
Date Signed: _______________________ Date Signed: _______________________ Date Signed: ________________________ Date Signed: ____________________
Degree: ___________________________ Degree: ___________________________ Degree: ____________________________ Degree: ________________________
a.) PRC NO: ______________________ PRC NO: __________________________ PRC NO: ___________________________ PRC NO: _______________________
Valid Until: __________________ Valid Until: ________________________ Valid Until: __________________________ Valid Until: ______________________
b.) PNA NO: _______________________ b.) PNA NO: _______________________ b.) PNA NO: _________________________ b.) PNA NO: ___________________
Valid Until: __________________ Valid Until: ________________________ Valid Until: __________________________ Valid Until: ______________________
 FAMILY CLINIC COLLEGES INC.
1452 A.H. Lacson St., Sampaloc, Manila, Philippine

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):_______________________________________________________________________________________________________

II. Minor Operations

Signature of
Date of Operation Type of Name of O.R.
No. Case No. Name of Patient Diagnosis Name of Surgeon Name of Hospital O.R. Scrub
Operation Performed Anesthesia Scrub Nurse
Nurse

1.

2.

3.

4.

5.

Noted by:

__________________________________ __________________________________ ___________________________________ ______________________________

Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief
Nurse Nurse Nurse Nurse
Date Signed: _______________________ Date Signed: _______________________ Date Signed: ________________________ Date Signed: ____________________
Degree: ___________________________ Degree: ___________________________ Degree: ____________________________ Degree: ________________________
b.) PRC NO: ______________________ PRC NO: __________________________ PRC NO: ___________________________ PRC NO: _______________________
Valid Until: __________________ Valid Until: _________________________ Valid Until: _________________________ Valid Until: ______________________
b.) PNA NO: _______________________ b.) PNA NO: _______________________ b.) PNA NO: ________________________ b.) PNA NO: _____________________
Valid Until: ___________________ Valid Until: ________________________ Valid Until: _________________________ Valid Until:
______________________
 FAMILY CLINIC COLLEGES INC.
1452 A.H. Lacson St., Sampaloc, Manila, Philippine

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

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

1.

2.

3.

4.

5.

Noted by:

__________________________________ __________________________________ ___________________________________ ______________________________

Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief
Nurse Nurse Nurse Nurse
Date Signed: _______________________ Date Signed: _______________________ Date Signed: ________________________ Date Signed: ____________________
Degree: ___________________________ Degree: ___________________________ Degree: ____________________________ Degree: ________________________
c.) PRC NO: ______________________ PRC NO: __________________________ PRC NO: ___________________________ PRC NO: _______________________
Valid Until: __________________ Valid Until: _________________________ Valid Until: _________________________ Valid Until: ______________________
b.) PNA NO: _______________________ b.) PNA NO: _______________________ b.) PNA NO: ________________________ b.) PNA NO: _____________________
Valid Until: ___________________ Valid Until: ________________________ Valid Until: _________________________ Valid Until:
______________________
 FAMILY CLINIC COLLEGES INC.
1452 A.H. Lacson St., Sampaloc, Manila, Philippine

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):_______________________________________________________________________________________________________

IV. Deliveries Assisted

Supervised by:
Name of Date of Time of Gender of
No. Case No. Diagnosis Age Name of Hospital Type of Delivery Signature of
Mother Delivery Delivery Baby
Qualified C.I.

1.

2.

3.

4.

5.

Noted by:

__________________________________ __________________________________ ___________________________________ ______________________________

Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief
Nurse Nurse Nurse Nurse
Date Signed: _______________________ Date Signed: _______________________ Date Signed: ________________________ Date Signed: ____________________
Degree: ___________________________ Degree: ___________________________ Degree: ____________________________ Degree: ________________________
d.) PRC NO: ______________________ PRC NO: __________________________ PRC NO: ___________________________ PRC NO: _______________________
Valid Until: __________________ Valid Until: _________________________ Valid Until: _________________________ Valid Until: ______________________
b.) PNA NO: _______________________ b.) PNA NO: _______________________ b.) PNA NO: ________________________ b.) PNA NO: _____________________
Valid Until: ___________________ Valid Until: ________________________ Valid Until: _________________________ Valid Until:
______________________
 FAMILY CLINIC COLLEGES INC.
1452 A.H. Lacson St., Sampaloc, Manila, Philippine

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):_______________________________________________________________________________________________________

V. Cord Dressing
Date Gender of Supervised by: Signature of
No. Case No. Name of Baby Name of Mother Age Name of Hospital
Performed Baby Qualified C.I.

1.

2.

3.

4.

5.

Noted by:

__________________________________ __________________________________ ___________________________________ ______________________________

Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Chief
Nurse Nurse Nurse Nurse
Date Signed: _______________________ Date Signed: _______________________ Date Signed: ________________________ Date Signed: ____________________
Degree: ___________________________ Degree: ___________________________ Degree: ____________________________ Degree: ________________________
e.) PRC NO: ______________________ PRC NO: __________________________ PRC NO: ___________________________ PRC NO: _______________________
Valid Until: __________________ Valid Until: _________________________ Valid Until: _________________________ Valid Until: ______________________
b.) PNA NO: _______________________ b.) PNA NO: _______________________ b.) PNA NO: ________________________ b.) PNA NO: _____________________
Valid Until: ___________________ Valid Until: ________________________ Valid Until: _________________________ Valid Until: _____________________