OUR LADY OF FATIMA UNIVERSITY

120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student: SURNAME, FIRST NAME MIDDLE NAME (PUT A COMMA AFTER SURNAME) _____
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program : ___ ____
Year Graduated (BSN Program): _____________________

I. MAJOR OPERATIONS
Date of Signature of O.R.
Case Name of Operation Type of Name of Name of O.R. Certified Clinical
No. Operatio Diagnosis Name of Hospital Certified Clinical
No. Patient Performed Anesthesia Surgeon Instructor
n Instructor

1.

2.

3.

4.

5.
AIDA V. GARCIA, RN, MAN
Signature over printed name of Clinical Coordinator
Noted by: MARICRIS_ C._ NONO_ RN, MAN______ Date Signed:
Signature over printed name of Chief Nurse LURCELI L. SANTOS, RN,RM MAN
Degree: BSN, MAN
Date Signed: _ Signature over printed name of Dean
a.) PRC NO : 0196716 _____
Degree: ____BSN, MAN _____ ______ Date Signed: _
Valid Until: MARCH 30, 2011
a.) PRC NO: 328823 ______ Degree: ______ BSN, __MAN
b.) PNA NO: 022841
Valid Until: DECEMBER 23, 2010_____ a.) PRC NO: ___ 0010878___
Valid Until: DECEMBER 2010
b.) PNA NO: 19252 _ _______ Valid Until: __2011
Valid Until: LIFETIME ______ b.) PNA NO: ___3018
Valid Until: __LIFETIME ______
c.) ADPCN NO: _0635
Valid Until: DECEMBER 2010
 OUR LADY OF FATIMA UNIVERSITY
120 Mc Arthur Highway Marulas, Valenzuela City
Name of Student: MAMAR, NIDA HAMADO
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: 2004
Year Graduated (BSN Program): ____

II. MINOR OPERATIONS

Signature of O.R.
Date of Name of Operation Type of Name of Name of O.R. Certified Clinical
No. Case No. Diagnosis Name of Hospital Certified Clinical
Operation Patient Performed Anesthesia Surgeon Instructor
Instructor
Pregnancy Uterine 11
Dilatation President Diosdado
January 5, Elence C. weeks Age of Gestation Intravenous Dr. Hazel
1. 044762 and Macapagal Memorial
2008 Estanislao Gravida 4 Para 3, Sedation Balon
Curettage Medical Center
Abortion Incomplete
Seen President Diosdado
January 7, 4 centimeters Laceration Intravenous Dr. PR
2. 044732 Mitchell Suturing Macapagal Memorial
2008 Frontal Left Sedation Cruz
Berreth Medical Center
Excision Of Dr. President Diosdado
January 11, Enrique G. Fibro Epithelial Polyp Local
3. 20 OPD Polyp Left Ishmael Macapagal Memorial
2008 Santos Inner Aspect Left Thigh Anesthesia
Thigh Umali Medical Center
February21 Rolando Multiple Lacerated Wound Local Dr. Analee Navotas Emergency
4. 2009-138 Suturing
, 2009 Torillos on Both Wrist Anesthesia Dizon Lying-In Clinic
Lacerated Wound
February 2, Michelle Local Dr. Analee Navotas Emergency
5. 2009-142 4.5 centimeters Right Suturing
2009 Aquino Anesthesia Dizon Lying-In Clinic
Hand

Noted by:
MARICRIS C. NONO RN, MAN ___________ AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM MAN
Signature over printed name of Chief Nurse Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Date Signed: _ Date Signed: Date Signed: _____
Degree: ____BSN, MAN_______ ______ Degree: BSN, MAN Degree: BSN, MAN _____
a.) PRC NO: 328823______ ______ a.) PRC NO: 0196716 a.) PRC NO: 0010878 _____
Valid Until: DECEMBER 23, 2010_____ Valid Until: MARCH 2011 Valid Until 2011 _____
b.) PNA NO: 19252______ _______ b.) PNA NO: 022841 b.) PNA NO: 3018 _____
Valid Until: LIFETIME___ ______ Valid Until: DECEMBER 2010 Valid Until: LIFETIME _____
c.) ADPCN NO: 0635 _______
Valid Until: 2010 _____
 OUR LADY OF FATIMA UNIVERSITY
120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student:_______________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program): ___

III. ACTUAL DELIVERIES

Case Name of Date of Time of Gender Name of Type of Supervised By: Signature of O.R. /DR
No. Diagnosis Age
No. Mother Delivery Delivery of Baby Hospital Delivery Clinical Instructor
Pregnancy Uterine Full Term Valenzuela Normal
Aida May M. September 3,
1. 34058 Gravida 1 Para 1 23 9:10 AM Female Medical Center Spontaneous
Donayne 2007
Cephalic in Labor Delivery

Pregnancy Uterine Full Term Valenzuela Normal

Babylyn September 10,
2. 22221 Gravida 1 Para 1 21 10:20 AM Male Medical Center Spontaneous
Manalog 2007
Cephalic in Labor Delivery
Pregnancy Uterine Full Term Valenzuela Normal
Maria Soccoro September 11,
3. 52413 Gravida 8 Para 7 31 9:55 AM Male Medical Center Spontaneous
C. Villanueva 2007
Cephalic in Labor Delivery
Pregnancy Uterine Full Term Navotas Normal
December 31,
4. 9461 Gravida 2 Para 4 Catherine Calo 24 8:40 PM Male Emergency Spontaneous
2008
Cephalic in Labor Lying-In Clinic Delivery
Pregnancy Uterine Full Term Navotas Normal
Gina Dela
5. 9481 Gravida 3 Para 2 30 January 9, 2009 9:35 PM Female Emergency Spontaneous
Cruz
Cephalic in Labor Lying-In Clinic Delivery
Noted by:
MARICRIS C. NONO RN, MAN_________
AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM, MAN
Signature over printed name of Chief Nurse
Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Date Signed:
Date Signed: Date Signed:
Degree: ____BSN, MAN__
Degree: BSN, MAN Degree: BSN, MAN
a.) PRC NO: 328823_____
a.) PRC NO: 0196716 a.) PRC NO: 0010878
Valid Until: DECEMBER 23, 2010____
Valid Until: MARCH 2011 Valid Until: 2011
b.) PNA NO: 19252_
b.) PNA NO: 022841 b.) PNA NO: 3018
Valid Until: LIFETIME __
Valid Until: DECEMBER 2010 Valid Until: LIFETIME
b.) PNA NO: _______ _____
c.) ADPCN NO: 0635
Valid Until: ____________
Valid Until: 2010
 OUR LADY OF FATIMA UNIVERSITY
120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student: _____ __________________

Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program): _______

IV. DELIVERIES ASSISTED

Case Name of Date of Time of Gender Name of Type of Supervised By: Signature of O.R. /DR
No. Diagnosis Age
No. Mother Delivery Delivery of Baby Hospital Delivery Clinical Instructor
Pregnancy Uterine Full Term Valenzuela Normal
September 4,
1. 48938 Gravida 1 Para 1 Manulot Dupa 28 11:34 AM Female Medical Center Spontaneous
2007
Cephalic in Labor Delivery

Pregnancy Uterine Full Term Valenzuela Normal

Miriam A. September 5,
2. 56439 Gravida 1 Para 1 20 9:45 AM Male Medical Center Spontaneous
Andres 2007
Cephalic in Labor Delivery
Pregnancy Uterine Full Term Valenzuela Normal
Nancy September 12,
3. 57445 Gravida 4 Para 3 34 2:05 AM Female Medical Center Spontaneous
Empeño 2007
Cephalic in Labor Delivery
Pregnancy Uterine Full Term Navotas Normal
December 31,
4. 9460 Gravida 4 Para 4 Norma Pader 29 8:05 AM Male Emergency Spontaneous
2008
Cephalic in Labor Lying-In Clinic Delivery
Pregnancy Uterine Full Term Navotas Normal
5. 9463 Gravida 1 Para 1 Alma Nicolas 23 January 4, 2009 10:05 AM Male Emergency Spontaneous
Cephalic in Labor Lying-In Clinic Delivery
Noted by:

_______________________
MARICRIS C. NONO RN MAN__ AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM, MAN
________________ Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Signature over printed name of Chief Nurse Date Signed: Date Signed:
Date Signed: ______________ Degree: BSN, MAN Degree: BSN, MAN
Degree: BSN, MAN_______ a.) PRC NO: 0196716 a.) PRC NO: 0010878
a.) PRC NO: _ 328823_________________ Valid Until: MARCH 2011 Valid Until: 2011
Valid Until: DECEMBER 23, 2010_____ b.) PNA NO: 022841 b.) PNA NO: 3018
b.) PNA NO: _19252__ Valid Until: DECEMBER 2010 Valid Until: LIFETIME
Valid Until: _LIFETIME c.) ADPCN NO: 0635
Valid Until: 2010
 OUR LADY OF FATIMA UNIVERSITY
120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student: ______________________

Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: ______
Year Graduated (BSN Program): _______

V. CORD DRESSING
Case Gender of Supervised By: Signature of O.R. /DR
No. Date Performed Name of Baby Name of Mother Age Name of Hospital
No. Baby Clinical Instructor

Valenzuela Medical
1. 56380 September 4, 2007 Baby Openda Male Analyn Openda 25
Center

Valenzuela Medical
2. 3076 September 5, 2007 Baby Solis Female Regine Solis 26
Center

Valenzuela Medical
3. 56526 September 5, 2007 Baby Cristobal Male Apple T. Cristobal 17
Center

President Diosdado
4. 044791 January 9, 2008 Bay Lagman Female Mylyn T. Lagman 27 Macapagal Memorial
Medical Center
President Diosdado
Estrella C.
5. 044806 January 11, 2008 Baby Conception Female 31 Macapagal Memorial
Conception
Medical Center
Noted by:
________________________
MARICRIS NONO RN, MAN AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM, MAN
Signature over printed name of Chief Nurse Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Date Signed: Date Signed: Date Signed:
Degree: BSN, MAN _____ Degree: BSN, MAN Degree: BSN, MAN
a.) PRC NO: 328823 ______ a.) PRC NO: 0196716 a.) PRC NO: 0010878
Valid Until: DECEMBER 23, 2010_____ Valid Until: MARCH 2011 Valid Until: 2011
b.) PNA NO: 19252 _____ b.) PNA NO: 022841 b.) PNA NO: 3018
Valid Until: LIFETIME______________ Valid Until: DECEMBER 2010 Valid Until: LIFETIME
c.) ADPCN NO: 0635
Valid Until: 2010
-

3. ONCE SIGNED BY CI and NOD,

The CI will submit the forms to CAS

105 for signing w/ Mam Garcia & Dean
1.Students are required to accomplish
every cut off
and submit this form to their Clinical
NCM 105 PROF.will release the forms Instructor
to GRP LEADER EVERY WED AND
1 form per hospital
FRI AT PJP 5TH FLOOR or PJP FACULTY
ROOM AT 5PM TO 6PM…

2. Clinical instructor

-will check the data

-If correct, to be signed by CI and

Nurse On Duty