ARELLANO UNIVERSITY

COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) in _____________ANTIPOLO DISTRICT HOSPITAL, ANTIPOLO ,RIZAL ______

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student _____NAZAR, MARIA MIKAELA A.____

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
July 19,2010 S.C.E. Total Abdominal
4:45 pm 10-10179 Hysterectomy Bilateral Peter Narvaez, R.N. Marilyn D. Ferreras , RN.,
Salphingo Oopherectomy MAN

Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) in ___DAGUPAN DOCTORS VILLAFLOR_MEMORIAL HOSPITAL DAGUPAN, PANGASINAN_____

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student __NAZAR, MARIA MIKAELA A._________

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
9-7-2010 A.D.T. Extracapsular Cataract Angelie Cabande, RN Mrs. Evelyn S. Cruz, RN
8:10 am 09100011550 Extraction Right eye

9-30-2010 C.G.P. Partial Laminectomy Angelie Cabande, RN Mrs. Evelyn S. Cruz , RN

1:15pm 09100000092
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) in __MOTHER TERESA OF CALCUTTA MEDICAL CENTER SAN FERNANDO CITY,PAMPANGA_____
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student __NAZAR, MARIA MIKAELA A._________

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
12- 30-2010 K.A.P.
12:15 pm 038109 Caesarean Section Jeffrey L. Sun ,BSN, RN, RM Jeffrey L. Sun ,BSN, RN, RM
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Minor) in ___MOTHER TERESA MEDICAL CENTER, SAN FERNANDO CITY, PAMPANGA___
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ____NAZAR,MARIA MIKAELA A._____________

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
12-30-2010 T.V.M.
10:00 am 038121 Excision of Penile Mass Jeffrey L. Sun, BSN, RN, RM Jeffrey L. Sun, BSN, RN, RM
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ASSISTED DELIVERY in___MOTHER TERESA MEDICAL CENTER, SAN FERNANDO CITY, PAMPANGA___
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student __NAZAR, MARIA MIKAELA A._____

Date Patient’s INITIAL PROCEDURE D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only PERFORMED Signature) Clinical
and (If Midwife on Duty, Signature instructor
Time Case Number ASSISTED Not Required) Name and
Started (not applicable for DELIVERY Signature
Birthing/Lying-
in Clinic/Home)
12-30- 2010 D.A.S.
8:52 am 038127 Normal Spontaneous Jeffrey L. Sun, BSN, RN, RM Jeffrey L. Sun, BSN, RN, RM
Delivery
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ASSISTED DELIVERY in ______ANTIPOLO DISTRICT HOSPITAL, ANTIPOLO, RIZAL_____

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student __NAZAR, MARIA MIKAELA A._____

Date Patient’s INITIAL PROCEDURE D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only PERFORMED Signature) Clinical
and (If Midwife on Duty, Signature instructor
Time Case Number ASSISTED Not Required) Name and
Started (not applicable for DELIVERY Signature
 Birthing/Lying-
in Clinic/Home)

7-20-2010 R.G.T.
3:15 pm 10-10318 Normal Spontaneous Peter Narvaez, RN Marilyn D. Ferreras, RN, MAN
Delivery

Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ACTUAL DELIVERY in____ MANDALUYONG CITY MEDICAL CENTER, MANDALUYONG CITY _______
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ________NAZAR, MARIA MIKAELA A.___
 Date Patient’s INITIAL PROCEDURE D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only PERFORMED Signature) Clinical
and (If Midwife on Duty, Signature instructor
Time Case Number Not Required) Name and
Started (not applicable for Signature
Birthing/Lying-
in Clinic/Home)
1-17-2011 L.P.T.
6:25 am 542380 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery
1-17-2011 C.A.M.
1:16 pm 542379 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery
1-24-2011 I.G.D.
1:35 pm 542542 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery
1-25-2011 J.L.M.
7:29 am 542636 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery

Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)
 ASSISTED DELIVERY in______MANDALUYONG CITY MEDICAL CENTER, MANDALUYONG CITY___
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student _______NAZAR, MARIA MIKAELA A.____

Date Patient’s INITIAL PROCEDURE D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only PERFORMED Signature) Clinical
and (If Midwife on Duty, Signature instructor
Time Case Number ASSISTED Not Required) Name and
Started (not applicable for DELIVERY Signature
Birthing/Lying-
in Clinic/Home)
1-17-2011 M.S.B.
10:43 am 542456 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery
1-24-2011 M.G.D.B.
7:34 am 542563 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery
1-25-2011 M.N.H.
8:06 am 542661 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery
1-25-2011 A.J.T.
11:57 am 542623 Normal Spontaneous Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
Delivery

Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

IMMEDIATE NEWBORN CORD CARE in ______MANDALUYONG CITY MEDICAL CENTER, MANDALUYONG CITY___
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ____NAZAR, MARIA MIKAELA A.___

Date Patient’s INITIAL Immediate Newborn Cord D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only Care Signature) Clinical
and PERFORMED (If Midwife on Duty, Signature instructor
Time Case Number Indicate where performed Not Required) Name and
Started (not applicable for e.g. D.R., Signature
Birthing/Lying- Nursery, NICU, or Home
in Clinic/Home)
1-17-2011 Baby Boy L.J.T.
6:25 am 542400 Delivery room Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
1-17-2011 Baby Boy C.A.M.
2:16 pm 542385 Delivery room Luciana Q. Peregrin, RN Teresa J. Dimayacyac ,RN
1-24-2011 Baby Boy I.G.D.
1:35 pm 5542578 Delivery room Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN
1-25- 2011 Baby Boy M.N.H.
8:06 am 542678 Delivery room Luciana Q. Peregrin ,RN Teresa J. Dimayacyac ,RN

Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

IMMEDIATE NEWBORN CORD CARE in ______ANTIPOLO DISTRICT HOSPITAL, ANTIPOLO, RIZAL_______

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ____NAZAR, MARIA MIKAELA A.___

Date Patient’s INITIAL Immediate Newborn Cord D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only Care Signature) Clinical
and PERFORMED (If Midwife on Duty, Signature instructor
Time Case Number Indicate where performed Not Required) Name and
Started (not applicable for e.g. D.R., Signature
Birthing/Lying- Nursery, NICU, or Home
in Clinic/Home)

7-20-2010 V.A.R. D.R. Peter Narvaez, RN Marilyn D. Ferreras, RN, MAN

2:10 pm 1010668
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY
COLLEGE of NURSING
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Minor) in _____________RIZAL PROVINCIAL HOSPITAL MORONG, RIZAL___________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student _______NAZAR, MARIA MIKAELA A.___

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
ARELLANO UNIVERSITY ODC Form 2A
COLLEGE of NURSING O.R. SCRUB MAJOR FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) in ______________________________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student _______NAZAR, MARIA MIKAELA A.___

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY ODC Form 2B

COLLEGE of NURSING O.R. SCRUB MINOR FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Minor) in ______________________________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student _______NAZAR, MARIA MIKAELA A.___

Date Performed Patient’s INITIAL SURGICAL O.R. Nurse On SUPERVISED

and Only PROCEDURE Duty BY
Time Started PERFORMED (Name and Clinical
Case Number Signature) instructor
Name and
Signature
Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ARELLANO UNIVERSITY ODC Form 1A

COLLEGE of NURSING ACTUAL DELIVERY FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ACTUAL DELIVERY in______________________________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ________NAZAR, MARIA MIKAELA A.___
 Date Patient’s INITIAL PROCEDURE D.R. Nurse On Duty (Name and SUPERVISED BY
Performed Only PERFORMED Signature) Clinical
and (If Midwife on Duty, Signature instructor
Time Case Number Not Required) Name and
Started (not applicable for Signature
Birthing/Lying-
in Clinic/Home)

Noted by: Emilie M. Lopez, RN, MAN Approved by: ROBERTO C. SOMBILLO,
RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 0157036 Valid Until August 28,2011 Dean, PRC I.D. No. 0172832 Valid Until
August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time:
_____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN