DAVAO MEDICAL SCHOOL FOUNDATION, INC.

COLLEGE OF NURSING
Medical School Drive, Bajada, Davao City, Philippines

Name of Student: ________________________________________

Name & Address of School: ________________________________________
Accreditation Level: (if any) ________________ Year Granted: _________
Date School/Program was Recognized: _March 10, 2006_ Number: _008_ Year: _2006_
First Course (if any): __________________ School Graduated From: ______________
Year of Admission in the Bachelor of Science in Nursing Program: ________
Year Graduated (BSN Program): _______
III. ACTUAL DELIVERIES
Supervised by:
Case Date of Time of Gender of
No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery Name & Signature of
No. Delivery Delivery Baby
Qualified C.I.

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

___ _______ ___ ________________________________

Signature over printed Name of Clinical Coordinator Signature over printed Name of Officer in Charge Signature over printed Name of Dean Signature over printed Name of Student
Date Signed: ___________________ Date Signed: ____________________ Date Signed: _______________
Degree: _ ___ Degree: _ ___ Degree: _ ___
a. PRC No.: _ a. PRC No.: _ ____________ a. PRC No.: _ __
Valid Until: _ ___ Valid Until: _ __ Valid Until: _ __
b. PNA No.: _ __ b. PNA No.: _ __ b. PNA No.: _ __
Valid Until: _ ___ Valid Until: _ _ Valid Until: _ _____
c. ANSAP No.: _ __ c. ADPCN No.: _ __
Valid Until: _ _ Valid Until: _ ___
 DAVAO MEDICAL SCHOOL FOUNDATION, INC.
COLLEGE OF NURSING
Medical School Drive, Bajada, Davao City, Philippines

Name of Student: ________________________________________

Name & Address of School: ________________________________________
Accreditation Level: (if any) ________________ Year Granted: _________
Date School/Program was Recognized: _March 10, 2006_ Number: _008_ Year: _2006_
First Course (if any): __________________ School Graduated From: ______________
Year of Admission in the Bachelor of Science in Nursing Program: ________
Year Graduated (BSN Program): _______
I. MAJOR OPERATION
Supervised by:
Date of Case Operation Type of Name of Name of O.R. Signature of O.R.
No. Name of Patient Diagnosis Name of Surgeon Name & Signature
Operation No. Performed Anesthesia Hospital Scrub Nurse Scrub Nurse
of Qualified C.I.

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

___ _______ ___ ________________________________

Signature over printed Name of Clinical Coordinator Signature over printed Name of Officer in Charge Signature over printed Name of Dean Signature over printed Name of Student
Date Signed: ___________________ Date Signed: ____________________ Date Signed: _______________
Degree: _ ___ Degree: _ ___ Degree: _ ___
a. PRC No.: _ a. PRC No.: _ ____________ a. PRC No.: _ __
Valid Until: _ ___ Valid Until: _ __ Valid Until: _ __
b. PNA No.: _ __ b. PNA No.: _ __ b. PNA No.: _ __
Valid Until: _ ___ Valid Until: _ _ Valid Until: _ _____
c. ANSAP No.: _ __ c. ADPCN No.: _ __
Valid Until: _ _ Valid Until: _ ___
 DAVAO MEDICAL SCHOOL FOUNDATION, INC.
COLLEGE OF NURSING
Medical School Drive, Bajada, Davao City, Philippines

Name of Student: ________________________________________

Name & Address of School: ________________________________________
Accreditation Level: (if any) ________________ Year Granted: _________
Date School/Program was Recognized: _March 10, 2006_ Number: _008_ Year: _2006_
First Course (if any): __________________ School Graduated From: ______________
Year of Admission in the Bachelor of Science in Nursing Program: ________
Year Graduated (BSN Program): _______

II. MINOR SCRUBS

Supervised by:
Date of Case Operation Type of Name of Name of O.R. Signature of O.R.
No. Name of Patient Diagnosis Name of Surgeon Name & Signature
Operation No. Performed Anesthesia Hospital Scrub Nurse Scrub Nurse
of Qualified C.I.

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

___ _______ ___ ________________________________

Signature over printed Name of Clinical Coordinator Signature over printed Name of Officer in Charge Signature over printed Name of Dean Signature over printed Name of Student
Date Signed: ___________________ Date Signed: ____________________ Date Signed: _______________
Degree: _ ___ Degree: _ ___ Degree: _ ___
a. PRC No.: _ a. PRC No.: _ ____________ a. PRC No.: _ __
Valid Until: _ ___ Valid Until: _ __ Valid Until: _ __
b. PNA No.: _ __ b. PNA No.: _ __ b. PNA No.: _ __
Valid Until: _ ___ Valid Until: _ _ Valid Until: _ _____
c. ANSAP No.: _ __ c. ADPCN No.: _ __
Valid Until: _ _ Valid Until: _ ___
 DAVAO MEDICAL SCHOOL FOUNDATION, INC.
COLLEGE OF NURSING
Medical School Drive, Bajada, Davao City, Philippines

Name of Student: ________________________________________

Name & Address of School: ________________________________________
Accreditation Level: (if any) ________________ Year Granted: _________
Date School/Program was Recognized: _March 10, 2006_ Number: _008_ Year: _2006_
First Course (if any): __________________ School Graduated From: ______________
Year of Admission in the Bachelor of Science in Nursing Program: ________
Year Graduated (BSN Program): _______
IV. DELIVERIES ASSISTED
Time of Gender Supervised by:
No. Case No. Diagnosis Name of Patient Age Date of Delivery Name of Hospital Type of Delivery
Delivery of Baby Name & Signature of C.I.

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

___ _______ ___ ________________________________

Signature over printed Name of Clinical Coordinator Signature over printed Name of Officer in Charge Signature over printed Name of Dean Signature over printed Name of Student
Date Signed: ___________________ Date Signed: ____________________ Date Signed: _______________
Degree: _ ___ Degree: _ ___ Degree: _ ___
a. PRC No.: _ a. PRC No.: _ ____________ a. PRC No.: _ __
Valid Until: _ ___ Valid Until: _ __ Valid Until: _ __
b. PNA No.: _ __ b. PNA No.: _ __ b. PNA No.: _ __
Valid Until: _ ___ Valid Until: _ _ Valid Until: _ _____
c. ANSAP No.: _ __ c. ADPCN No.: _ __
Valid Until: _ _ Valid Until: _ ___
 DAVAO MEDICAL SCHOOL FOUNDATION, INC.
COLLEGE OF NURSING
Medical School Drive, Bajada, Davao City, Philippines

Name of Student: ________________________________________

Name & Address of School: ________________________________________
Accreditation Level: (if any) ________________ Year Granted: _________
Date School/Program was Recognized: _March 10, 2006_ Number: _008_ Year: _2006_
First Course (if any): __________________ School Graduated From: ______________
Year of Admission in the Bachelor of Science in Nursing Program: ________
Year Graduated (BSN Program): _______

V. CORD CARE
Date Gender of Supervised by:
No. Case No. Name of Baby Name of Mother Age Name of Hospital
Performed Baby Name & Signature of C.I.

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

___ _______ ___ ________________________________

Signature over printed Name of Clinical Coordinator Signature over printed Name of Officer in Charge Signature over printed Name of Dean Signature over printed Name of Student
Date Signed: ___________________ Date Signed: ____________________ Date Signed: _______________
Degree: _ ___ Degree: _ ___ Degree: _ ___
a. PRC No.: _ a. PRC No.: _ ____________ a. PRC No.: _ __
Valid Until: _ ___ Valid Until: _ __ Valid Until: _ __
b. PNA No.: _ __ b. PNA No.: _ __ b. PNA No.: _ __
Valid Until: _ ___ Valid Until: _ _ Valid Until: _ _____
c. ANSAP No.: _ __ c. ADPCN No.: _ __
Valid Until: _ _ Valid Until: _ ___