WEST NEGROS UNIVERSITY

(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS

COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

I. MAJOR SCRUBS
Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended

Primary Low Transverse Teresita L. Jalandoni

1 10:40 PM 11:30 PM June 24, 2009 09-0635 Arsenia, Jumawa Spinal Norma Calicdan
Cesarean Section Provincial Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA RAMON S. LEONORAS JR. MICHELLE M. TABAY MA. TERESA O. SEVERINO LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MAN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0487745 a) PRC No.: 0334554 a) PRC No.: 0101938 a) PRC No.: 0157222
Valid Until: December 26, 2011 Valid Until: May 19, 2013 Valid Until: April 27, 2011 Valid Until: September 21, 2010
b) PNA No.: 045339 b) PNA No.: 025854 b) PNA No.: 17418 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

I. MAJOR SCRUBS
Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended
Corazon Locsin
Total Abdominal Continuous Lumbar
2 10:45 AM 1:50 PM August 17, 2009 01126760 Belarmino, Rosemarie Ma. Elnalyn Acuerdo Montelibano Memorial
Hysterectomy Epidural Block
Regional Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA BELLE C. PAPARON MICHELLE M. TABAY JORESLYN P. BALA-AN LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MA. Ed., MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0086493 a) PRC No.: 0334554 a) PRC No.: 0091019 a) PRC No.: 0157222
Valid Until: August 22, 2010 Valid Until: May 19, 2013 Valid Until: May 24, 2011 Valid Until: September 21, 2010
b) PNA No.: 10553 b) PNA No.: 025854 b) PNA No.: 03879 b) PNA No.: 9706
Valid Until: Lifetime Member Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

I. MAJOR SCRUBS
Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended
Repeat Low Segment
The Doctor’s Hospital,
3 3:23 PM 4:45 pm February 11, 2010 159032 Mayang, Rizza Cesarean Section, Spinal Ledi Almaiz Tan L.
Inc.
Adhesolysis

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA RANDY C. CATAGUE MICHELLE M. TABAY EDITHA L. BAYONETA LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0426384 a) PRC No.: 0334554 a) PRC No.: 0125661 a) PRC No.: 0157222
Valid Until: February 25, 2013 Valid Until: May 19, 2013 Valid Until: August 8, 2012 Valid Until: September 21, 2010
b) PNA No.: 045224 b) PNA No.: 025854 b) PNA No.: 19677 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

I. MAJOR SCRUBS
Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended
Cholecystectomy Common
Vile Duct Exploration intra The Doctors’ Hospital,
4 10:25 AM 2:25 PM February 12, 2010 159071 Tubongbanua, Julio Spinal / General Ramon Villanueva
Operative Cholargyogram Inc.
Choledochod uodenostomy

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA BELLE C. PAPARON MICHELLE M. TABAY EDITHA L. BAYONETA LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0086493 a) PRC No.: 0334554 a) PRC No.: 0125661 a) PRC No.: 0157222
Valid Until: August 22, 2010 Valid Until: May 19, 2013 Valid Until: August 8, 2012 Valid Until: September 21, 2010
b) PNA No.: 10553 b) PNA No.: 025854 b) PNA No.: 19677 b) PNA No.: 9706
Valid Until: Lifetime Member Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

I. MAJOR SCRUBS
Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended
Ignacio l. Arroyo
5 10:00 AM 12:00 NN January 03, 2009 09000111 Gahol, Nicolas Closure of Palate and Lip General Klaus Exner Memorial District
Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA MA. CHERYL C. GENERALES MICHELLE M. TABAY ROSE MARY P. GAYARES LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN Degree: RM, RN, MN Degree: RN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0169163 a) PRC No.: 0334554 a) PRC No.: 0034577 a) PRC No.: 0157222
Valid Until: April 10, 2012 Valid Until: May 19, 2013 Valid Until: December 25, 2011 Valid Until: September 21, 2010
b) PNA No.: 021545 b) PNA No.: 025854 b) PNA No.: 021546 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

II. MINOR SCRUBS

Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended

December 13, Removal, Foreign Body, The Doctor’s Hospital,

1 6:15 PM 6:25 PM 159223 Mata, Ritchell Local Julian Rizaldy Raca
2010 Thumb, Right Inc.

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA JULIANA M. NIEGO MICHELLE M. TABAY EDITHA L. BAYONETA LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0077524 a) PRC No.: 0334554 a) PRC No.: 0125661 a) PRC No.: 0157222
Valid Until: July 20, 2012 Valid Until: May 19, 2013 Valid Until: August 8, 2012 Valid Until: September 21, 2010
b) PNA No.: 9903 b) PNA No.: 025854 b) PNA No.: 19677 b) PNA No.: 9706
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Valid Until: Lifetime Member Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

II. MINOR SCRUBS

Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended

2 1:30 PM 1:45 PM May 1, 2010 1147 Arby M. Arroyo Circumcision Local

Dr. Jose C. Locsin
Daniel T. Paez Memorial
Maternal Clinic
3 2:45 PM 3:00 PM May 1, 2010 1145 John Lester Guarin Circumcision Local

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA DONNA P. JAVELONA MICHELLE M. TABAY ARLENE G. CHU LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR PUBLIC HEALTH NURSE III DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0263971 a) PRC No.: 0334554 a) PRC No.: 0088075 a) PRC No.: 0157222
Valid Until: February 8, 2013 Valid Until: May 19, 2013 Valid Until: February 26, 2011 Valid Until: September 21, 2010
b) PNA No.: 045622 b) PNA No.: 025854 b) PNA No.: 044403 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member

II. MINOR SCRUBS

Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended

Novy Ann Teresita L. Jalandoni

4 6:26 AM 7:00 AM May 2, 2010 10-0518 Jalbuena, Rea Marie Completion Curettage IV Sedation
Buensureso Provincial Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA RAFAEL C. MARMOLEJO III MICHELLE M. TABAY MA. TERESA O. SEVERINO LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0260390 a) PRC No.: 0334554 a) PRC No.: 0101938 a) PRC No.: 0157222
Valid Until: June 27, 2013 Valid Until: May 19, 2013 Valid Until: April 27, 2011 Valid Until: September 21, 2010
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

b) PNA No.: 045285 b) PNA No.: 025854 b) PNA No.: 17418 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

II. MINOR SCRUBS

Time Time
No. Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Started Ended
Ignacio L. Arroyo
Debridement of Necrotic
5 9:00 AM 10:00 AM October 25, 2009 090007240 Samad, Doroteo IM Sedation Lalaine Teorima Memorial District
Tissues
Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA MA. CHERYL C. GENERALES MICHELLE M. TABAY ROSE MARY P. GAYARES LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN Degree: RM, RN, MN Degree: RN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0169163 a) PRC No.: 0334554 a) PRC No.: 0034577 a) PRC No.: 0157222
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Valid Until: April 10, 2012 Valid Until: May 19, 2013 Valid Until: December 25, 2011 Valid Until: September 21, 2010
b) PNA No.: 021545 b) PNA No.: 025854 b) PNA No.: 021546 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member

III. ACTUAL DELIVERIES

Time of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery
Delivery
Well-Family Midwife
Pregnancy Uterine Full Term Normal Spontaneous
1 00-02-05 Liberty, Villaflor 28 December 28, 2009 7:30 PM Female Clinic, Villamonte,
Gravida 2 Para 2 Vaginal Delivery
Bacolod City

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA DONNA P. JAVELONA MICHELLE M. TABAY EDITH M. MONTIBOR LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CLINIC MANAGER DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RM Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0263971 a) PRC No.: 0334554 a) PRC No.: 0084399 a) PRC No.: 0157222
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Valid Until: February 8, 2013 Valid Until: May 19, 2013 Valid Until: November 12, 2012 Valid Until: September 21, 2010
b) PNA No.: 045622 b) PNA No.: 025854 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member

III. ACTUAL DELIVERIES

Time of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery
Delivery
Pregnancy Uterine Full Term
2 10124 Salavante, Showvy 22 April 30, 2010 1:27 AM Male
Gravida 1 Para 1 Dr. Jose C. Locsin
Normal Spontaneous
Memorial
Vaginal Delivery
Pregnancy Uterine Full Term Maternal Clinic
3 10125 Hermocillas, Annie Rose 25 April 30, 2010 5:23 AM Female
Gravida 2 Para 2

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA DONNA P. JAVELONA MICHELLE M. TABAY ARLENE G. CHU LOURDES B. MAGBANUA
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR PUBLIC HEALTH NURSE III DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0263971 a) PRC No.: 0334554 a) PRC No.: 0088075 a) PRC No.: 0157222
Valid Until: February 8, 2013 Valid Until: May 19, 2013 Valid Until: February 6, 2011 Valid Until: September 21, 2010
b) PNA No.: 045622 b) PNA No.: 025854 b) PNA No.: 044403 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member

III. ACTUAL DELIVERIES

Time of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery
Delivery
Pregnancy Uterine Full Term
4 00-04-44 Solanob, Roselyn 26 May 11, 2010 2:00 AM Male
Gravida 1 Para 1 Well-Family Midwife
Normal Spontaneous
Clinic, Villamonte,
Vaginal Delivery
Pregnancy Uterine Full Term Bacolod City
5 00-29-100 Lozano, Grace 20 May 12, 2010 5:00 PM Male
Gravida 1 Para 1

Prepared by: Supervised by: Noted by: Concurred by: Approved by:
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

ANDREW M. JALBUENA DONNA P. JAVELONA MICHELLE M. TABAY EDITH M. MONTIBOR LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CLINIC MANAGER DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RM Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0263971 a) PRC No.: 0334554 a) PRC No.: 0084399 a) PRC No.: 0157222
Valid Until: February 8, 2013 Valid Until: May 19, 2013 Valid Until: November 12, 2012 Valid Until: September 21, 2010
b) PNA No.: 045622 b) PNA No.: 025854 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member

IV. ASSISTED DELIVERIES

Time of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery
Delivery
Corazon Locsin
0111827 Pregnancy Uterine Full Term Normal Spontaneous
1 Cabardo, Remegia 35 June 22, 2009 9:33 PM Male Montelibano Memorial
8 Gravida 4 Para 4 Vaginal Delivery
Regional Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA MOLY V. CALAMAY MICHELLE M. TABAY JORESLYN P. BALA-AN LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MA. Ed., MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 02626240 a) PRC No.: 0334554 a) PRC No.: 0091019 a) PRC No.: 0157222
Valid Until: November 6, 2010 Valid Until: May 19, 2013 Valid Until: May 24, 2011 Valid Until: September 21, 2010
b) PNA No.: 044699 b) PNA No.: 025854 b) PNA No.: 03879 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

IV. ASSISTED DELIVERIES

Time of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery
Delivery
Corazon Locsin
Pregnancy Uterine Full Term Normal Spontaneous
2 00-29-27 Villaverde, Moonyeen 43 August 22, 2009 9:33 PM Male Montelibano Memorial
Gravida 6 Para 6 Vaginal Delivery
Regional Hospital

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA JOJI V. ESPINOSA MICHELLE M. TABAY JORESLYN P. BALA-AN LOURDES B. MAGBANUA
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN

CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN Degree: RM, RN, MN Degree: RN, MA. Ed., MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 71195 a) PRC No.: 0334554 a) PRC No.: 0091019 a) PRC No.: 0157222
Valid Until: December 9, 2010 Valid Until: May 19, 2013 Valid Until: May 24, 2011 Valid Until: September 21, 2010
b) PNA No.: 045297 b) PNA No.: 025854 b) PNA No.: 03879 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

IV. ASSISTED DELIVERIES

Time of
No. Case No. Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery
Delivery
Pregnancy Uterine Full Term
3 00-28-39 Francisio, Rudelyn 19 April 26, 2010 3:17 AM Female Well-Family Midwife
Gravida 2 Para 2 Normal Spontaneous
Clinic, Villamonte,
Pregnancy Uterine Full Term Vaginal Delivery
4 00-28-37 Ederlyn, Yanson 26 April 26, 2010 3:20 PM Male Bacolod City
Gravida 1 Para 1
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Pregnancy Uterine Full Term

5 00-28-43 Macariza, Chery Mae G. 18 April 26, 2010 5:35 PM Female
Gravida 1 Para 1

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA DONNA P. JAVELONA MICHELLE M. TABAY EDITH M. MONTIBOR LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CLINIC MANAGER DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RM Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0263971 a) PRC No.: 0334554 a) PRC No.: 0084399 a) PRC No.: 0157222
Valid Until: February 8, 2013 Valid Until: May 19, 2013 Valid Until: November 12, 2012 Valid Until: September 21, 2010
b) PNA No.: 045622 b) PNA No.: 025854 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member

V. CORD DRESSING
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital
Teresita L. Jalandoni Provincial
1 09-3581 August 23, 2009 Boy “A” Robles Male Robles, Joanna 20
Hospital
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA ROSELYN D. GERIA MICHELLE M. TABAY MA. TERESA O. SEVERINO LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0143420 a) PRC No.: 0334554 a) PRC No.: 0101938 a) PRC No.: 0157222
Valid Until: May 13, 2011 Valid Until: May 19, 2013 Valid Until: April 27, 2011 Valid Until: September 21, 2010
b) PNA No.: 021571 b) PNA No.: 025854 b) PNA No.: 17418 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

V. CORD DRESSING
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital

2 155129 December 17, 2009 Despojo Baby Girl Female Aliza Yu Despojo 32 The Doctors’ Hospital, Inc.
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA PALMYRA PRUDENCIA S. ROSALIA MICHELLE M. TABAY EDITHA L. BAYONETA LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0488173 a) PRC No.: 0334554 a) PRC No.: 0125661 a) PRC No.: 0157222
Valid Until: December 5, 2011 Valid Until: May 19, 2013 Valid Until: August 8, 2012 Valid Until: September 21, 2010
b) PNA No.: 045223 b) PNA No.: 025854 b) PNA No.: 19677 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

V. CORD DRESSING
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital

3 155243 December 19, 2009 Fuentespina Bb. Boy Male Angie Lee Fuentespina 25 The Doctors’ Hospital, Inc.
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA MOLY V. CALAMAY MICHELLE M. TABAY EDITHA L. BAYONETA LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CHIEF NURSE DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RN, MN Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 02626240 a) PRC No.: 0334554 a) PRC No.: 0125661 a) PRC No.: 0157222
Valid Until: November 6, 2012 Valid Until: May 19, 2013 Valid Until: August 8, 2012 Valid Until: September 21, 2010
b) PNA No.: 044699 b) PNA No.: 025854 b) PNA No.: 19677 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member Valid Until: Lifetime Member

V. CORD DRESSING
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital
4 00-28-36 December 25, 2009 Masula Marc Joshua, A. Male Gazelle Masula 31 Well-Family Midwife Clinic, Villamonte
Bacolod City
 WEST NEGROS UNIVERSITY
(Formerly WEST NEGROS COLLEGE) SPECIFIED FORMS & SCRUBS
COLLEGE OF NURSING As per PRC Resolution No. 357 Series 2004
Burgos St., Bacolod City and PRC-BON Memorandum No. 01, S.2008

Name of Student: JALBUENA, ANDREW MONTINOLA First Course (if any): Year:
Date of School Program was Recognized: Effective SY 1995 - 1996 School Graduate from:
Accreditation Level: Year of Admission in the BSN Program: June 2007
Year Graduated from the BSN Program: May 29, 2010

5 00-28-42 December 31, 2009 Bacaoco Vallieclythe, G. Female Tissa Bacaoco 22

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

ANDREW M. JALBUENA DONNA P. JAVELONA MICHELLE M. TABAY EDITH M. MONTIBOR LOURDES B. MAGBANUA
NAME OF EXAMINEE CLINICAL INSTRUCTOR CLINICAL COORDINATOR CLINIC MANAGER DEAN
CTC Number: 06479400 Date Signed: Date Signed: Date Signed: Date Signed:
Date: July 21, 2010 Degree: RN, MN Degree: RM, RN, MN Degree: RM Degree: RM, RN, RT, MAN, Ph. D.
Place: Bacolod City a) PRC No.: 0263971 a) PRC No.: 0334554 a) PRC No.: 0084399 a) PRC No.: 0157222
Valid Until: February 8, 2013 Valid Until: May 19, 2013 Valid Until: November 12, 2012 Valid Until: September 21, 2010
b) PNA No.: 045622 b) PNA No.: 025854 b) PNA No.: 9706
Valid Until: October 31, 2010 Valid Until: October 31, 2010 Valid Until: Lifetime Member