OUR LADY OF FATIMA UNIVERSITY

#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

Name of Student: CAPLIS, ERWIN REFUERZO_____ __________________________________________________________________________ ________________
Name and Address of School: OUR LADY OF FATIMA UNEVRSITY, #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY___________________
Accreditation Level (if any): PACUCOA LEVEL II_____________________Year Granted: April 10, 2002___________________________________________________________
Date School/Program was Recognized: April 25, 2001________________Number: 033________________________Year: 2001_______________________________________
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: _2003__________________________________________________________________________________
Year Graduated (BSN Program): _2009_____________________________________________________________________________________________________________

II. Minor Operations

Date of Case Operation Type of Name of Signature of
No. Name of Patient Diagnosis Name of Surgeon Name of Qualified CI
Operation No. Performed Anesthesia Hospital Qualified CI
Marcellus C. Belisario
Bulacan Maternity
December 16, 1160712 Incomplete Abortion Dilatation and Intravenous Dra. Pricilla RN,MAN
1. 2007 6558
Jonalyn Mendoza
Gravida3 Para2 Curettage Anesthesia Quiambao
and Childrens
Hospital PRC No: 0349993
PNA No: 19636
November 19, 1119071 Bilateral Tubal Ligation Bilateral Tubal Dra. Pricilla
Bulacan Maternity Marcellus C. Belisario
2. 2007 34348
Amante Nonita
Gravida6 Para3 Ligation
Spinal Anesthesia
Quiambao
and Childrens PRC No: O349993
Hospital PNA No: 19636
Jonel Ramirez RN, MAN
Lacerated Wound Right Batangas
3. May 13 ,2008 369700 Catilo Benedict
Temporal
Suturing of Wound Local Anesthesia Dr. Mark Louie
Regional Hospital
PRC No; 450849
PNA No: 2256
Jonel Ramirez RN, MAN
Batangas Regional
4. May 13, 2008 369935 Alilio John Hilbert Infected Wound Left Foot Debridement Local Anesthesia Dr. Edmund Reyes PRC No: 450849
Hospital
PNA No: 2256
Jonel Ramirez RN,MAN
Mark Kien Batangas Regional
5. May 13, 2008 369937 Uncircumcised Penis Circumcission Local Anesthesia Dra. Clareta Dita PRC No: 450849
Macalalad Hospital
PNA No: 2256

Prepared by:
Noted by: Concurred by: Concurred by: Approved by:
CAPLIS, ERWIN REFUERZO__
Mr s. MA RIS OL G AR CIA -MAN IP OL , AMOR CALAYAN, RN,RM,MAN,PH.D.__ MINERVA N. ESPINO, RN, ____ __ NELIA R. CAPULONG,_RN,RM,MAN____
Signature over printed Name of Student
RN, MAN Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Dean
Supervised by:
,

MARCELLUS C. BELISARIO, RN,MAN
Signature over printed name of Faculty
Date Signed: ____________________
Degree: RN,MAN________ _ Valid Until: October 10, 2009_________
PRC No: 0349993___________ ___
Valid Until: September 12, 2012__
PNA No: 19636 ______________
Valid Until:_Liifetime ____
Signature over printed name of Clinical
Coordinator
Date Signed: ______________________
Degree:__BSN, MAN________________
a.) PRC NO: _0296870_____________
Valid Until: September 2012______
b.) PNA NO: __025883 _____________
Valid Until:_December 2009 ______
Date Signed: ______________________
Degree:_BSN,RM,MAN,RN, PhD_______
a.) PRC NO: _151514 ______
Valid Until: August 2010__________
b.) PNA NO: _038801____ _________
Valid Until: December 2009_______
Date Signed: _______________________
Degree:_RN,BSN___________________
a.) PRC NO: 0090530_________________
b.) ANSAP NO: ______________________
Valid Until: _______________________
c.) PNA NO: _19638 ________________
Valid Until: Lifetime _______
Date Signed: ______________________
Degree:_BSN,RN, RM, MAN_________
a.) PRC NO: 0041904______________
Valid Until: July 31, 2012______ __
b.) PNA NO: 18698__________________
Valid Until: Lifetime______________
b.) ADPCN NO:_0627______________
Valid Until: December 2009_______
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: CAPLIS, ERWIN REFEURZO __________________________________________________________________________________-__________________
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY___________________
Accreditation Level (if any): PACUCOA LEVEL II_____________________Year Granted: April 10, 2002____________________________________________________________
Date School/Program was Recognized: April 25, 2001________________Number: 033 Year: 2001_____________________________________________
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: 2003___________________________________________________________________________________
Year Graduated (BSN Program): 2009______________________________________________________________________________________________________________

I. Major Operations
Date of Operation Type of Name of Signature of
No. Case No. Name of Patient Diagnosis Name of Hospital Name of Qualified CI
Operation Performed Anesthesia Surgeon Qualified CI
Marcellus C. Belisario
Pregnancy Uterine 37 Dra. Ma. Bulacan Maternity
Caesarian Spinal RN,MAN
1. December 132732 Basillo Ruth weeks gestation Cephalic Grace Agnes and Childrens
Section Anesthesia PRC No: 0349993
13, 2007 in Labor Para6 Bautista Hospital
PNA No: 19636
Marcellus C. Belisario
Pregnancy Uterine Full Bulacan Maternity
December Ma. Thersa Caesarian Spinal Dra. Pricilla RN,MAN
2. 088171 Term, cephalic in Labor and Childrens
19, 2007 Castro Section Anesthesia Quiambao PRC No: 0349993
Gravida3 Para1 Hospital
PNA No: 19636
Jonel Ramirez RN,MAN
August 27, Ruptured Appendix Exploratory Subarachnoid Dr. Aristotle Batangas Regional
3. 381315 Rodel Dayte PRC No;450849
2008 Laparotomy Anesthesia Arellano Hospital
PNA No: 2256
Combined
Jonel Ramirez RN,MAN
August 29, Spinal and Dr. Jose Batangas Regional
4. 373456 Jose Benemer Cholelithiasis Cholecystectomy PRC No: 450849
2008 Epedural Tenorio Hospital
PNA No: 2256
Anesthesia
Jonel Ramirez RN,MAN
August 29, Exploratory Laparotomy Closure of Subarachnoid Dr. Aristotle Batangas Regional
5. 364339 Edgardo Paner PRC No: 450848
2008 colostomy colostomy Anesthesia Arellano Hospital
PNA NO: 2256
Approved by:
Prepared by: Noted by: Concurred by: Concurred by: NELIA R. CAPULONG, RN,RM,MAN__
CAPLIS, ERWIN REFUERZO___ MRS. MARISOL GARCIA-MANIPOL, _MINERVA ESPINO, RN ____ AMOR CALAYAN RN,RM,MAN,PH.D. Signature over printed name of Dean
Signature over printed Name of Student RN,MAN Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
Supervised by: Signature over printed name of Clinical Date Signed: ______________________
JONEL RAMIREZ, RN,MAN ______ Date Signed: ______________________ Date Signed: _______________________ Degree:_BSN RN,RM, MANMAN______
Coordinator Degree:_BSN,RN___________________ Degree:_BSN, RN_RM,MAN, PH.D._____
Signature over printed name of Faculty Date Signed: ______________________ c.) PRC NO: 0041904______________
Date Signed: ____________________ a.) PRC NO:_0090530________________ a.) PRC NO: _151514 _____________
Degree:__BSN, MAN________________ Valid Until: October 10, 2009________ Valid Until: _August 2010____________ Valid Until: July 31, 2012 _______
Degree: RN,MAN________________
PRC No: 450849_________________ b.) PRC NO: _0296870_____________ b.) ANSAP NO: _____________________ b.) PNA NO: _038801 ______________ b.) PNA NO: 18698__________________
Valid Until: September 2012______ Valid Until: ______________________ Valid Until: _December 2009_______ Valid Until: Lifetime______________
Valid Until: September 2010_____
b.) PNA NO: __025883______________ c.) PNA NO: 19638 _______________ c.) ADPCN NO:_0627________________
PNA No: 2256 _____________ Valid Until:_December 2009______ Valid Until: _Lifetime _______ Valid Until: December 2009_________
Valid Until: December 2009
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: CALIS ERWIN REFUERZO _______________________________________________________________________________ __________________
Name and Address of School: OUR LADY OF FATIMA UNEVRSITY, #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY____________________
Accreditation Level (if any): PACUCOA LEVEL II_____________________Year Granted: April 10, 2002___________________________________________________________
Date School/Program was Recognized: April 25, 2001________________Number: 033________________________Year: 2001_______________________________________
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: _2003__________________________________________________________________________________
Year Graduated (BSN Program): _2009_____________________________________________________________________________________________________________

III. Actual Deliveries

Name of Date of Time of Gender Supervised by: Name and Signature of
No. Case No. Diagnosis Age Name of Hospital Type of Delivery
Mother Delivery Delivery of Baby Qualified C.I.
Pregnancy Uterine Full Term Normal Rosanie C. Moro RN,PH.D
Novaliches District
1. 142607 Gravida 2, Para 0, 39 weeks Age Melissa Corpus 27 Jily 23, 2007 2:06 am Female Spontaneous PRC No: 66491
Hospital
of Gestation, Cephalic in Labor Delivery PNA NO: 25665
Pregnancy Uterine Full Term Normal Rosanie C. Moro RN,PH.D
Novaliches District
2. 161401 Gravida 2, Para 1 39 weeks Age Aquino Karen 26 June 3, 2008 12:10 am Female Spontaneous PRC No: 66491
Hospital
of Gestation, Cephalic in Labor Delivery PNA No: 25665
Pregnancy Uterine Full Term Ospital ng Lungsod ng Normal Norberta Alcarion RN,RM,MAN
November 16,
3. 621134 Gravida 4, Para 3, 39 weeks Age Sally Almodan 34 7:30 pm Male San Jose Del Monte Spontaneous PRC No: 170101
2008
of Gestation, Cephalic in Labor Bulacan Delivery PNA No: 1077
Pregnancy Uterine Full Term Ospital ng Lungsod ng Normal Norberta C. Alcarion RN,RM,MAN
January 3,
4. 398629 Gravida 1, Para 0, 38 weeks Age Maricar Ruego 24 11:00 pm Female San Jose Del Monte Spontaneous PRC No: 170101
2009
of Gestation, Cephalic in Labor Bulacan Delivery PNA No: 1077
Pregnancy Uterine Full Term Ospital ng Lungsod ng Normal Norberta C. Alcarion RN,RM,MAN
January 4,
5. 398586 Gravida 2, Para 1 38 weeks Age Celerina Arias 21 7:40 pm Female San Jose Del Monte Spontaneous PRC No: 170101
2009
of Gestation, Cephalic in Labor Bulacan Delivery PNA No: 1077

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

CAPLIS, ERWIN REFUERZO__
Signature over printed Name of Student
Supervised by:
NORBERTA C.
ALCARION,RN,RM,MAN
Signature over printed name of Faculty
Date Signed: ___________________
Degree: _BSN,RN,RM, MAN _ Valid Until: September 2012 _____
PR C No : 170101 __________
Valid Until; June 6, 2012____
PNA No : 1077 ___________
Valid Un til: December 2009
Mrs. MARISOL GARCIA- MANIPOL,
RN,MAN
Signature over printed name of Clinical
Coordinator
Date Signed: ______________________
Degree:__BSN,RN, MAN____________
c.) PRC NO: _0296870_____________
b.) PNA NO: __025883 ____________
Valid Until: December 2009______
Concurred by:
ESTELITA B. LORENZO RN,RM,MAN
Signature over printed name of Chief Nurse
Date Signed: _______________________
Degree:_RN,RM,MAN __________
a.) PRC NO: _0111348________________
Valid Until: September 3, 2011_______
b.) PNA NO: 1078 _____________
Valid Until: _December 2009_________
JOSEPHINE B.
LEONARDO_RN,MAN,PH.D.
Signature over printed name of Chief Nurse
Date Signed: ___________________
Degree: BSN,RN,MAN, PH.D_______
a.) PRC NO: 0081174__________
Valid Until:_ April 3, 2011_____
b.) PNA NO: _15614______________
Valid Until:_Lifetime_____
NELIA R. CAPULONG, RN, RM, MAN__
Signature over printed name of Dean
Date Signed: ______________________
Degree:_BSN, RM, MAN_____________
d.) PRC NO: 0041904______________
Valid Until: July 31, 2012________
b.) PNA NO: 18698__________________
Valid Until: Lifetime______________
c.) ADPCN NO:_0627________________
Valid Until: December 2009_________
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: CAPLIS, ERWIN REFEURZO ________________________________________________________-_______________________________________
Name and Address of School: OUR LADY OF FATIMA UNEVRSITY, #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY______________________
Accreditation Level (if any): PACUCOA LEVEL II_____________________Year Granted: April 10, 2002___________________________________________________________
Date School/Program was Recognized: April 25, 200 Number: 033 Year: 2001_______________________________________________________________________
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: 2003___________________________________________________________________________________
Year Graduated (BSN Program): _2009_____________________________________________________________________________________________________________

IV. Deliveries Assisted

Case Date of Time of Gender Supervised by: Name and
No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery
No. Delivery Delivery of Baby Signature of Qualified C.I.
Pregnancy Uterine Full Term Gravida Rosanie C. Moro RN,PhD
August 1, Novaliches District Normal Spontaneous
1. 143095 3, Para 2, 38 weeks Age of Ma. Farat Seasat 28
2007
3:15 am Male
Hospital Delivery
PRC No: 66491
Gestation, Cephalic in Labor PNA NO: 25665
Pregnancy Uterine Full Term Gravida Rosanie C. Moro RN,PhD
June 2, Novaliches District Normal Spontaneous
2. 161278 2, Para 1, 39 weeks Age of Aquino Doloures 25 11;15 am Male PRC No: 66491
2008 Hospital Delivery
Gestation, Cephalic in Labor PNA No: 25665
Pregnancy Uterine Full Term Gravida Rosanie C. Moro RN,PhD
June 1o, Novaliches District Normal Spontaneous
3. 161827 2, Para 1, 38 weeks Age of Allama Sherry 25 8:12 am Female PRC No: 66491
2008 Hospital Delivery
Gestation, Cephalic in Labor PNA No: 25665
Pregnancy Uterine Full Term Gravida Rosanie C. Moro RN,PhD
July 8, Novaliches District Normal Spontaneous
4. 152775 1, Para 0, 40 weeks Age of Serino,Mery Kris 18 9:30 am Female PRC No: 66491
Gestation, Cephalic in Labor
2008 Hospital Delivery
PNA No: 25665
Pregnancy Uterine Full Term Gravida Ospital ng Lungsod ng Norberta C. Alcarion RN,RM,MAN
January 5, Normal Spontaneous
5. 398629 2, Para 1 40 weeks Age of Gestation, Jovlyn Riego 27 2:01 am Male San Jose Del Monte PRC No: 170101
2009 Delivery
Cephalic in Labor Bulacan PNA No: 1077

Prepared by:
CAPLIS, ERWIN REFUERZO___ Noted by: Concurred by: JO SE PH INE B . LE ON ARD O_ Concurred by: Approved by:
Mrs. MAR ISO L GAR CI A- M AN IPO L, RN, MAN RN, MAN, Ph. D . ESTELITA B. LORENZO RN,RM,MAN NELIA R. CAPULONG RN,RM,MAN
Supervised by: Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Dean
Signature over printed name of Clinical Coordinator
ROSANIEover
Signature C. MORO
printed,_RN,
NamePH.D._____
of Student Date Signed: ______________________ Date Signed: __________________
Date Signed: ___________________ Date Signed: ____________________ Degree:_RN, RM, MAN___________
Signature over printed name of Faculty
_______________________________
Degree:_BSN, RN, MAN__________ Degree:__BSN.,RN,MAN,PH.D_______ Degree:_RN, RM, MAN______________
Date Signed: ____________________
Degree: BSN, RN,PH.D ______ a.) PRC NO: __0081174____________ a.) PRC NO: _0111348_______________
e.) PRC NO: 0041904__________
d.) PRC NO: _0296870__________ Valid Until: _April 3, 2011________ Valid Until: July 31, 2012_____
PRC No: 66491 _________ Valid Until: September 2012__
Valid Until: _September 3, 2011_____
b.) PNA NO: 18698______________
b.) PNA NO: _1078 __________
Valid Until; November 8, 2009 b.) PNA NO: __025883___________ b.) PNA NO: __15614______________
Valid Until: ___December 2009 ___ Valid Until: Lifetime_________
Valid Until:__December 2009__ Valid Until: _Lifetime___________
PNA No: 25665 ___________ c.) ADPCN NO:_0627__ ________
Valid Until: December 2009___
Valid Until: December 2009____
 OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: CAPLIS, ERWIN REFUERZO_________________________________________________________________________________________
Name and Address of School: OUR LADY OF FATIMA UNEVRSITY, #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY_____________________
Accreditation Level (if any): PACUCOA LEVEL II_____________________Year Granted: April 10, 2002____________________________________________________________
Date School/Program was Recognized: April 25, 2001________________Number: 033________________________Year: 2001_______________________________________
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: _2003__________________________________________________________________________________
Year Graduated (BSN Program): __2009___________________________________________________________________________________________________________-

V. Cord Dressing
Date Gender of Supervised by: Signature of Qualified
No. Case No. Name of Baby Name of Mother Age Name of Hospital
Performed Baby C.I.
Rosanie C. Moro RN,PhD
1. 142608 July 24, 2007 Baby Girl Ritchelle Female Rirchelle Gelbolingo 28 Novaliches District Hospital PRC No: 66491
PNA NO: 25665
Rosanie C. Moro RN,PhD
2. 161279 June 2, 2008 Baby Boy Mauricio Male Mauricio Leanie 22 Novaliches District Hospital PRC No: 66491
PNA No: 25665
Norberta C. Alcarion RN,RM,MAN
January 5, Ospital ng Lungsod ng San Jose Del
3. 398815 Baby Girl Joli Female Joli Gabalda San Juan 23 Monte Bulacan
PRC No: 170101
2009 PNA No: 1077
Norberta C. Alcarion RN,RM,MAN
January 5, Ospital ng Lungsod ng San Jose Del
4. 358616 Baby Boy Coredes Male Teresita Coredes 25 PRC No: 170101
2009 Monte Bulacan
PNA No: 1077
Norberta C. Alcarion RN,RM,MAN
January 5, Ospital ng Lungsod ng San Jose Del
5. 398603 Baby Boy Mangao Male Mery Joy Mangao 21 Monte Bulacan
PRC No: 170101
2009 PNA No: 1077Approved by:
NELIA R. CAPULONG RN,RM.MAN
Prepared by: Noted by: Concurred by: Concurred by: Signature over printed name of Dean
CAPLIS, ERWIN REFUERZO___ Mrs. MARISOL GARCIA- MANIPOL, ESTELITA B. LORENZO_RN,RM,MAN__ JOSEPHINE B. LEONARDO RN,MN,PH.D. Date Signed: __________________
Supervised by: RN,MAN Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
Degree:_BSN,RN, RM, MAN______
NORBERTA C. ALCARION, RN,M,MAN Signature over printed name of Clinical Date Signed: ____________________ Date Signed: ________________________
Signature over printed name of Faculty Coordinator f.) PRC NO: 0041904__________
Degree:_BSN,RM, RN, MAN _______ Degree: RN,MAN,PH.D_______________
Date Signed: ____________________ Valid Until: July 31, 2012____
Date Signed: ___________________ a.) PRC NO: __0081174______________
Degree: BSN,RM,RN,MAN__________ a.) PRC NO: ___0111348__________ b.) PNA NO: 18698______________
Degree:_BSN,RN , MAN___________ Valid Until: _April 3, 2011 ______
PRC No: 170101___________ Valid Until: _September 3, 2011__ Valid Until: Lifetime__________
e.) PRC NO: _0296870___________ b.) PNA NO: ___15614 _____________
.) ADPCN NO:_0627_____________
Valid Until; June 6, 2012_____ Valid Until: September 2012___ b.) PNA NO: __1078_____________ Valid Until:___Lifetime ___________
Valid Until: December 2009____
PNA No: 1077_____________ b.) PNA NO: 025883 ____________ Valid Until: __December 2009_____
Valid Until:_December 2009_____
Valid Until: December 2009