Name of Student:_________________________________________________________________________________________________________

First Course (if any) :_______________________________________________________

Name and Address of School: Holy Trinity University_____________________________________________________________________________
School Graduated From: ___________________________________________________
Quezon St., Puerto Princesa City, Palawan____________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________
Accreditation Level (if any): PAASCU Level 1________________________ Year Graduated (BSN Program):______________________________________________
Date School/Program was Recognized: June 10, 1991________________

I. Major Operations
Date of Case Name of Type of Type of Name of Name of Name of Signature of
No. Medical Diagnosis
Operation No. Patient Surgery Anesthesia Surgeon Hospital Qualified C.I. Qualified C.I.

1.

2.

3.

4.

5.

Supervised By:_____________________________________________________________
(Signature over printed name of Clinical Supervisor)
Date Signed:__________________________________________________________________
Degree:BSN, RN, MAN__________________________________________________________
a.) PRC NO: _________________________________________________________________
Valid Until: ________________________________________________________________
b.) PNA NO: __________________________________________________________________
Valid Until: ________________________________________________________________

Noted by: AGNES B. PALAO, R.N.,M.A.N.,Ph.D._____________ Noted By: _ MARIA CELINA G. CASIS, RN, MSN, DScN _
(Signature over printed name of Chief Nurse) (Signature over printed name of Dean)
Date Signed: ____________________________ Date Signed: _________________________________________________________________
Degree:BSN, RN, MPA, Ph.D._______________ Degree:______________________________________________________________________
PRC NO: _______________________________Valid Until: _________________ PRC NO: _______________________________Valid Until_____________________________
PNA NO: 12564__________________________Valid Until: Lifetime Member___ PNA NO: ______________________________Valid Until: _____________________________
ADPCN NO:_____________________________Valid Until: ____________________________

Name of Student:_________________________________________________________________________________________________________
Name and Address of School: Holy Trinity University_______________________________________
Quezon St., Puerto Princesa City, Palawan____________________________________________________________________________________
School Graduated From: ___________________________________________________
Accreditation Level (if any): PAASCU Level 1________________________ Year of Admission in the Bachelor of Science in Nursing Program: __________________
Date School/Program was Recognized: June 10, 1991________________ Year Graduated (BSN Program):______________________________________________
First Course (if any) :_______________________________________________________

II. Minor Scrubs

Date of Case Name of Type of Type of Name of Name of Name of Signature of
No. Medical Diagnosis
Operation No. Patient Surgery Anesthesia Surgeon Hospital Qualified C.I. Qualified C.I.

1.

2.

3.

4.

5.

Supervised By:______________________________________________________________
(Signature over printed name of Clinical Supervisor)
Date Signed:__________________________________________________________________
Degree:BSN, RN, MAN__________________________________________________________
b.) PRC NO: _________________________________________________________________
Valid Until: ________________________________________________________________
b.) PNA NO: __________________________________________________________________
Valid Until: ________________________________________________________________
Noted by: AGNES B. PALAO, R.N.,M.A.N.,Ph.D._____________
(Signature over printed name of Chief Nurse) Noted By: _ MARIA CELINA G. CASIS, RN, MSN, DScN _
Date Signed: ____________________________ (Signature over printed name of Dean)
Degree:BSN, RN, MPA, Ph.D._______________ Date Signed: _________________________________________________________________
PRC NO: _______________________________Valid Until: _________________ Degree:______________________________________________________________________
PNA NO: 12564__________________________Valid Until: Lifetime Member___ PRC NO: _______________________________Valid Until_____________________________
PNA NO: ______________________________Valid Until: _____________________________
ADPCN NO:_____________________________Valid Until: ____________________________
Name of Student:_________________________________________________________________________________________________________
Accreditation Level (if any): PAASCU Level 1________________________
Name and Address of School: Holy Trinity University_____________________________________________________________________________
Date School/Program was Recognized: June 10, 1991________________
Quezon St., Puerto Princesa City, Palawan____________________________________________________________________________________
First Course (if any) :_______________________________________________________
School Graduated From: ___________________________________________________ Year Graduated (BSN Program):______________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________

III. Deliveries Handled

Name and Age of Gender of Signature of
No. Case No. Date of Delivery Time of Delivery Name of Hospital Name of Qualified C.I.
Patient Baby Qualified C.I.

1.

2.

3.

4.

5.

Supervised By:_______________________________________________________________
(Signature over printed name of Clinical Supervisor)
Date Signed:__________________________________________________________________
Degree:BSN, RN, MAN__________________________________________________________
c.) PRC NO: _________________________________________________________________
Valid Until: ________________________________________________________________
b.) PNA NO: __________________________________________________________________
Valid Until: ________________________________________________________________
Noted by: AGNES B. PALAO, R.N.,M.A.N.,Ph.D._____________
(Signature over printed name of Chief Nurse) Noted By: _ MARIA CELINA G. CASIS, RN, MSN, DScN _
Date Signed: ____________________________ (Signature over printed name of Dean)
Degree:BSN, RN, MPA, Ph.D._______________ Date Signed: _________________________________________________________________
PRC NO: _______________________________Valid Until: _________________ Degree:______________________________________________________________________
PNA NO: 12564__________________________Valid Until: Lifetime Member___ PRC NO: _______________________________Valid Until_____________________________
PNA NO: ______________________________Valid Until: _____________________________
ADPCN NO:_____________________________Valid Until: ____________________________
Name of Student:_________________________________________________________________________________________________________
First Course (if any) :_______________________________________________________
Name and Address of School: Holy Trinity University_____________________________________________________________________________
School Graduated From: ___________________________________________________
Quezon St., Puerto Princesa City, Palawan____________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________
Accreditation Level (if any): PAASCU Level 1________________________ Year Graduated (BSN Program):______________________________________________
Date School/Program was Recognized: June 10, 1991________________
 IV. Deliveries Assisted
Gender of Signature of
No. Case No. Name and Age of Patient Date of Delivery Time of Delivery Name of Hospital Name of Qualified C.I.
Baby Qualified C.I.

1.

2.

3.

4.

5.

Supervised By:_______________________________________________________________
(Signature over printed name of Clinical Supervisor)
Date Signed:__________________________________________________________________
Degree:BSN, RN, MAN__________________________________________________________
d.) PRC NO: _________________________________________________________________
Valid Until: ________________________________________________________________
b.) PNA NO: __________________________________________________________________
Valid Until: ________________________________________________________________
Noted by: AGNES B. PALAO, R.N.,M.A.N.,Ph.D._____________
(Signature over printed name of Chief Nurse) Noted By: _ MARIA CELINA G. CASIS, RN, MSN, DScN _
Date Signed: ____________________________ (Signature over printed name of Dean)
Degree:BSN, RN, MPA, Ph.D._______________ Date Signed: _________________________________________________________________
PRC NO: _______________________________Valid Until: _________________ Degree:______________________________________________________________________
PNA NO: 12564__________________________Valid Until: Lifetime Member___ PRC NO: _______________________________Valid Until_____________________________
PNA NO: ______________________________Valid Until: _____________________________
ADPCN NO:_____________________________Valid Until: ____________________________
Name of Student:_________________________________________________________________________________________________________
First Course (if any) :_______________________________________________________
Name and Address of School: Holy Trinity University_____________________________________________________________________________
School Graduated From: ___________________________________________________
Quezon St., Puerto Princesa City, Palawan____________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________
Accreditation Level (if any): PAASCU Level 1________________________ Year Graduated (BSN Program):______________________________________________
Date School/Program was Recognized: June 10, 1991________________

V. Cord Dressing
 Gender of Signature of
No. Case No. Date of Delivery Name of Baby Name and Age of Mother Name of Hospital Name of Qualified C.I.
Baby Qualified C.I.

1.

2.

3.

4.

5.

Supervised By:______________________________________________________________
(Signature over printed name of Clinical Supervisor)
Date Signed:__________________________________________________________________
Degree:BSN, RN, MAN__________________________________________________________
e.) PRC NO: _________________________________________________________________
Valid Until: ________________________________________________________________
b.) PNA NO: __________________________________________________________________
Valid Until: ________________________________________________________________
Noted by: AGNES B. PALAO, R.N.,M.A.N.,Ph.D._____________
(Signature over printed name of Chief Nurse) Noted By: _ MARIA CELINA G. CASIS, RN, MSN, DScN _
Date Signed: ____________________________ (Signature over printed name of Dean)
Degree:BSN, RN, MPA, Ph.D._______________ Date Signed: _________________________________________________________________
PRC NO: _______________________________Valid Until: _________________ Degree:______________________________________________________________________
PNA NO: 12564__________________________Valid Until: Lifetime Member___ PRC NO: _______________________________Valid Until_____________________________
PNA NO: ______________________________Valid Until: _____________________________
ADPCN NO:_____________________________Valid Until: ____________________________