FIRST CITY PROVIDENTIAL COLLEGE

Francisco Homes Subdivision, City of San Jose del Monte, Bulacan

Name of Student:_________________________________________________________________________________________________________
Name and Address of School: First City Providential College, Francisco Homes Subdivision, CSJDM, Bulacan_______________________________
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
No. Date of Case Name of Patient Diagnosis Operation Type of Name of Name of Name of OR Name and
Operation No. Performed Anesthesia Surgeon Hospital Scrub Nurse Signature of
Qualified CI
1.

2.

3.

4.

5.

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

Ann Kathleen S. Belisario______
Signature over printed Name of Student _____________________ _________________________ Ligaya O. Lichauco, RN, MAN, Ph D
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ a.) PRC NO: ___________
Date Signed: ____________ b.) PRC NO: __________ a.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
a.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
 FIRST CITY PROVIDENTIAL COLLEGE
Francisco Homes Subdivision, City of San Jose del Monte, Bulacan

Name of Student:_________________________________________________________________________________________________________
Name and Address of School: First City Providential College, Francisco Homes Subdivision, CSJDM, Bulacan_______________________________
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

No. Date of Case No. Name of Patient Diagnosis Operation Type of Name of Surgeon Name of Hospital Name of OR Signature of
Operation Performed Anesthesia Scrub Nurse Qualified CI
1.

2.

3.

4.

5.

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

Ann Kathleen S. Belisario
Signature over printed Name of Student _____________________ _________________________ Ligaya O. Lichauco RN, MAN, Ph D
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ b.) PRC NO: ___________
Date Signed: ____________ d.) PRC NO: __________ b.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
c.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
 FIRST CITY PROVIDENTIAL COLLEGE
Francisco Homes Subdivison, City of San Jose del Monte, Bulacan

Name of Student:_________________________________________________________________________________________________________
Name and Address of School: First City Providential College, Francisco Homes Subdivision, CSJDM, Bulacan_______________________________
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

No. Case Diagnosis Name of Age Date of Time of Gender Name of Type of Delivery Supervised by:
No. Mother Delivery Delivery of Baby Hospital Signature of Qualified
C.I.
1.

2.

3.

4.

5.

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

_Ann Kathleen S. Belisario
Signature over printed Name of Student _____________________ _________________________ Ligaya O. Lichauco, RN, MAN, Ph. D
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ c.) PRC NO: ___________
Date Signed: ____________ f.) PRC NO: __________ c.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
e.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
 FIRST CITY PROVIDENTIAL COLLEGE
Francisco Homes Subdivision, City of San Jose del Monte, Bulacan

Name of Student:_________________________________________________________________________________________________________
Name and Address of School: First City Providential College, Francisco Homes Subdivision, CSJDM, Bulacan_______________________________
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

No. Case No. Diagnosis Name of Age Date of Time of Gender of Name of Hospital Type of Delivery Supervised by:
Mother Delivery Delivery Baby Signature of
Qualified C.I.
1.

2.

3.

4.

5.

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

_Ann Kathleen S. Belisario__
Signature over printed Name of Student _____________________ _________________________ Ligaya O. Lichauco, RN, MAN, Ph. D
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ d.) PRC NO: ___________
Date Signed: ____________ h.) PRC NO: __________ d.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
g.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
 FIRST CITY PROVIDENTIAL COLLEGE
Francisco Homes Subdivision, City of San Jose del Monte, Bulacan

Name of Student:_________________________________________________________________________________________________________
Name and Address of School: First City Providential College, Francisco Homes Subdivision, CSJDM, Bulacan_______________________________
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
No. Case No. Date Name of Baby Gender of Name of Mother Age Name of Hospital Supervised by: Signature of
Performed Baby Qualified C.I.
1.

2.

3.

4.

5.

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

_Ann Kathleen S. Belisario___
Signature over printed Name of Student _____________________ _________________________ Ligaya O. Lichauco, RN, MAN, Ph. D
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ e.) PRC NO: ___________
Date Signed: ____________ j.) PRC NO: __________ e.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
i.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________