PRC Form

University of Cebu
College of Nursing – Banilad Campus

Governor Cuenco Avenue, Banilad
Cebu City
Page 1 of 10
Name of Student: _____________________________________________________________________________________________________________________________________________________________
Name & Address of School: _University of Cebu - Banilad Governor Cuenco Avenue, Banilad, Cebu City_________________________________________________________________________________________________________
________
Accreditation Level (if any): _Level II – Third Reaccredited Status________________________________________________ Year Granted: 2007_____________________________________________________________________________
First Course (if any): ____________________________________________________________________________________ School Graduated From: ________________________________ Year: _______________________________
Year of Admission in the Bachelor of Science in Nursing Program: ____________________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): _2009____________________________________________________________________________________________________________________________________________________ ________________
I. Major Operations
Signature of
No Date of Type of Name of O.R.
Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital O.R. Scrub
. Operation Anesthesia Scrub Nurse
Nurse
Excision of Anterior
Don Enrico P. Chong Hua Eileen Gail O.
1 1/27/2006 93202 Princess Borja Epidermal Inclusion Cyst Neck Mass, Neck General
Garcia, M.D. Hospital Florendo, R.N.
Exploration
Cholecystectomy
with Intraoperative
Cholecystitis Hydrop Gallbladder Chong Hua
Cholangiogram, Achilles M. Cortes, Marga Rita M.
2 2/2/2006 93771 Warren N. Holganza Secondary to Stone at Cystic General Hospital
Common Bile Duct M.D. Esperanza, R.N.
Duct, Cholestorolosis
Exploration with T-
tube Insertion
Modified Radical Rogelio G. Chong Hua Eileen Gail O.

3 2/3/2006 93850 Eleonor N. Plasus Ductal Carcinoma Breast, Right General
Mastectomy, Right Kangleon Jr., M.D. Hospital Florendo, R.N.
Exploratory
Laparotomy
Sigmoidectomy with Kenneth S. Chan, Chong Hua
4 2/9/2006 94560 Ailil Ailette T. Phua Endometriosis General Sheila Niña A.
End to End M.D. Hospital
Basa, R.N.
Anastomosis, Frozen
Section
Chong Hua Montzheimer C.

5 2/10/2006 94448 Roland C. Co Acute Appendicitis Appendectomy Regional Iben A. Ting, M.D.
Hospital Preagido, R.N.
Prepared by:
_
Name of Student
Supervised by: Noted by: Concurred by: Approved by:
MS. MA. ESTELLA P. CABATANA______ MS. PILUCHI VICTORINA M. VILLEGAS_________ (NAME OF CHIEF NURSE)___________ DR. HELEN C. ESTRELLA_____________
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: ____________________ Date Signed: _____________________________ Date Signed: ________________________ Date Signed: ________________________
Degree: _MN__________________ Degree: MAN_____________________________ Degree: _ _______________________ Degree: _MN, DM____________________
a.) PRC No.: ____________________ a.) PRC No.: ‘0034689_______________________ a.) PRC No.: ________________________ a.) PRC No.: ‘0075238_________________
Valid until: ____________________ Valid until: June 15, 2012__________________ Valid until: ________________________ Valid until: June 19, 2011_____________
b.) PNA No.: ____________________ b.) PNA No.: _443__________________________ b.) PNA No.: ________________________ b.) PNA No.: 2764_____________________
Valid until: ____________________ Valid until: _Lifetime______________________ Valid until: ________________________ Valid until: Lifetime__________________
c.) ANSAP No.: ______________________ c.) ADCPN No.: 154____________________
Valid until: _______________________ Valid until: ___________________
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct, and complete statement pursuant to the provisions of pertinent laws, rules
and regulations of the Republic of the Philippines.
_______________________________________
Signature of Applicant
Subscribed and sworn to before me this _______ day of ___________________________ 20 ____, _________________________________________, Philippines.
NOTARY PUBLIC
University of Cebu
Cebu City
Page _3_ of _10_
Name of Student: ____________________________________________________________________________________________________________________________________________ ________________
Name & Address of School: _ University of Cebu - Banilad Governor Cuenco Avenue, Banilad, Cebu City _________________________________________________________________________________________________________
Accreditation Level (if any): ___________________________________________________________ Year Granted: ________________________________________________________________________ ________
Year of Admission in the Bachelor of Science in Nursing Program: ___________________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): __________________________________________________________________________________________________________________________________________________________________
II. Minor Operations

Signature of
No Date of Type of Name of O.R.
Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital O.R. Scrub
. Operation Anesthesia Scrub Nurse
Nurse
Severo Verallo
Excision of Mario M. Liezel P. Baldoza,
1 7/6/2006 06-66-77 Melody Metante Sebaceous Cyst Infected Chest Local Memorial
Sebaceous Cyst Fernandez, M.D. R.N.
Hospital
Severo Verallo
Mario M. Liezel P. Baldoza,
2 7/6/2006 045603 Alona E. Lanurias Perineal Laceration Episiorrhaphy Local Memorial
Fernandez, M.D. R.N.
Hospital
Inverting Papilloma, Nasal

Medial Maxillectomy Gina M. Seredrica, Chong Hua BJ C. Migallos,
3 8/31/2006 112364 Ma. Theresa Y. Lugue Cavity, Right, Status Post Punch General
Right M.D. Hospital R.N.
Biopsy
Excision of Mass, Visayas

Lymphoma Subscapular Area, Geraldine P. Gail Vera E.
4 9/7/2006 503555 Caridad Alipuyo Subscapular Area, Local Community
Left Yapha, M.D. Maco, R.N.
Left Medical Center
Cauterization of Jose Rizalito C. Chong Hua Lorelei G. Angot,

5 2/9/2007 127494 Joey E. Melencion Genital Warts Regional
Genital Warts Catipay, M.D. Hospital R.N.
Prepared by:
Name of Student
Supervised by: Noted by: Concurred by: Concurred by:
MS. MA. ESTELLA P. CABATANA __ MS. PILUCHI VICTORINA M. VILLEGAS_______ (NAME OF CHIEF NURSE)____________ (NAME OF CHIEF NURSE)____________
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
Date Signed: ____________________ Date Signed: _____________________________ Date Signed: ________________________ Date Signed: ________________________
Degree: _MN___________________ Degree: _________________________________ Degree: _MAN_______________________ Degree: _MAN_______________________
a.) PRC No.: ____________________ a.) PRC No.: ‘0034689_______________________ a.) PRC No.: ________________________ a.) PRC No.: ________________________
Valid until: ____________________ Valid until: June 15, 2009__________________ Valid until: ________________________ Valid until: ________________________
b.) PNA No.: ____________________ b.) PNA No.: _443__________________________ b.) PNA No.: ________________________ b.) PNA No.: ________________________
Valid until: ____________________ Valid until: _Lifetime______________________ Valid until: ________________________ Valid until: ________________________
c.) ANSAP No.: ______________________ c.) ANSAP No.: ______________________
Valid until: _______________________ Valid until: _______________________
Concurred by: Approved by:
(NAME OF CHIEF NURSE)_____________ DR. HELEN C. ESTRELLA ____________

Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: ________________________ Date Signed: ________________________
Degree: _MAN_______________________ Degree: _MN, MAN___________________
a.) PRC No.:_0173592__________________ a.) PRC No.: ‘0075238_________________
Valid until: May 28, 2009_____________ Valid until: June 19, 2008_____________
b.) PNA No.:11659_____________________ b.) PNA No.: 2764____________________
Valid until: 4/14/2007________________ Valid until: Lifetime_________________
Valid until: _______________________ Valid until: 2007____________________
_______________________________________
NOTARY PUBLIC
University of Cebu
Cebu City
Page _5_ of 10_
Name of Student: _ __________________________________________________________________________________________________________________________________________________________________________
Name & Address of School: _ University of Cebu - Banilad Governor Cuenco Avenue, Banilad, Cebu City _____________________________________________________________________________________________________________
Accreditation Level (if any): _ ____________________________________________________________ Year Granted: _______________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): __________________________________________________________________________________________________________________________________________________________________
III. Actual Deliveries

Supervised by:
No Date of Time of Gender
Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery Name & Signature of
. Delivery Delivery of Baby
Qualified C.I.
Pregnancy Uterine Full Term Visayas Community Medical Normal Spontaneous Mr. Mauro Allan P.
1 105685 Gemma Comajes 36 8/12/2005 8:42 AM Male
Age of Gestation: 38 weeks and 4 days Center Vaginal Delivery Amparado, RN, MAN
Pregnancy Uterine Full Term 10/13/200 Normal Spontaneous Mr. Mauro Allan P.
2 03118 Miguela M. Tumulak 36 4:20 PM Male Lapu-lapu District Hospital
Age of Gestation: 44 weeks and 2 days 5 Vaginal Delivery Amparado, RN, MAN
Pregnancy Uterine Full Term Normal Spontaneous Mr. Mauro Allan P.

3 06-09021 Flordeliza Deiparine 29 11/9/2006 5:55 AM Female Minglanilla District Hospital
Age of Gestation: 40 weeks and 5 days Vaginal Delivery Amparado, RN, MAN
Pregnancy Uterine Full Term Visayas Community Medical Normal Spontaneous Mr. Mauro Allan P.
4 286539 Chona L. Jumao-as 32 1/18/2007 3:20 PM Female
Age of Gestation: 37 weeks and 6 days Center Vaginal Delivery Amparado, RN, MAN

5 07-28921 Lucina Juntilla 33 4/8/2007 5:05 AM Female Danao District Hospital
Prepared by:
GARCIA, JOHN C
Name of Student
Supervised by: Noted by: Concurred by: Concurred by:
MRS. MERCY MILAGROSB. APUHIN MS. PILUCHI VICTORINA M. VILLEGAS __ (NAME OF CHIEF NURSE)_____________ Mrs. Grace C. Estremos_______________
Signature over printed name of Faculty Signature over printed name of Clinical Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
Date Signed: _________________________ Coordinator Date Signed: ________________________ Date Signed: ________________________
Degree: _MAN________________________ Date Signed: _____________________________ Degree: _MAN_______________________ Degree: _MAN_______________________
a.) PRC No.: Degree: _________________________________ a.) PRC No.:_0173592_________________ a.) PRC No.:_0043828__________________
‘0307204__________________ a.) PRC No.: ‘0034689_______________________ Valid until: May 28, 2009_____________ Valid until: December 2010____________
Valid until: March 3, Valid until: June 15, 2009__________________ b.) PNA No.:11659____________________ b.) PNA No.:___________________________
2010_____________ b.) PNA No.: _443__________________________ Valid until: 4/14/2007________________ Valid until:__________________________
b.) PNA No.: 16223_____________________ Valid until: _Lifetime______________________ c.) ANSAP No.: ______________________ c.) ANSAP No.:_213_____________________
Valid until: Valid until: _______________________ Valid until:_lifetime_________________
Concurred by: Concurred by: Approved by:
Mrs. Josifina A. Empaces___________ Mrs. Evelyn J. Monsanto_______________ Dr. Helen C.Estrella___________________

Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: ________________________ Date Signed: ________________________ Date Signed: ________________________
Degree: _MAN_______________________ Degree: _MAN_______________________ Degree: _MN, DM____________________
a.) PRC No.: ________________________ a.) PRC No.: ________________________ a.) PRC No.: ‘0075238_________________
Valid until: ________________________ Valid until: ________________________ Valid until: June 19, 2008____________
b.) PNA No.: ________________________ b.) PNA No.: ________________________ b.) PNA No.: 2764_____________________
Valid until: ________________________ Valid until: ________________________ Valid until: Lifetime__________________
c.) ANSAP No.: ______________________ c.) ANSAP No.: ______________________ c.) ADCPN No.: 154____________________
Valid until: _______________________ Valid until: _______________________ Valid until: 2007____________________
_______________________________________
NOTARY PUBLIC
University of Cebu
Cebu City
Page _7_ of 10
Name of Student:
Name & Address of School: _ University of Cebu - Banilad Governor Cuenco Avenue, Banilad, Cebu City
Accreditation Level (if any): Year Granted:
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

Supervised by:
No Date of Time of Gender
Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery Name & Signature of
. Delivery Delivery of Baby
Qualified C.I.
Pregnancy Uterine Full Term 12:03 Visayas Community Medical Normal Spontaneous Mr. Mauro Allan P.
1 279210 Yolanda Calo 25 8/18/2005 Male
Age of Gestation: 37 weeks and 2 days PM Center Vaginal Delivery Amparado, RN, MAN

2 065173 Lilian J. Bedio 27 7/1/2006 7:23 AM Male Severo Verallo Memorial Hospital
Pregnancy Uterine Full Term 10:40 Normal Spontaneous Mr. Mauro Allan P.
3 06-07985 Cathely R. Atienza 36 10/18/2006 Male Minglanilla District Hospital
Age of Gestation: 38 weeks and 6 days AM Vaginal Delivery Amparado, RN, MAN
Pregnancy Uterine Full Term 10:45 Normal Spontaneous Mr. Mauro Allan P.
4 06-09025 Maria Mylin Yungod 32 11/9/2006 Female Minglanilla District Hospital
Age of Gestation: 40 weeks and 5 days AM Vaginal Delivery Amparado, RN, MAN

5 07-03435 Jenny Rose A. Basalo 31 3/22/2007 9:50 AM Male Minglanilla District Hospital
Concurred by: Concurred by:

Prepared by:
Supervised by: Noted by: (NAME OF CHIEF NURSE) ___________ (NAME OF CHIEF NURSE)____________
Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse
MRS. MERCY MILAGROS B. APUHIN MS. PILUCHI VICTORINA M. VILLEGAS _______ Date Signed: ________________________ Date Signed: ________________________
Name of Student
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Degree: _ ______________________ Degree: _ _______________________
Date Signed: ____________________ Date Signed: _____________________________ a.) PRC No.: a.) PRC No.: ________________________
Degree: _MAN___________________ Degree: _________________________________ Valid until: ______________ Valid until: ________________________
a.) PRC No.: ‘0307204__________ __ a.) PRC No.: ‘0034689_______________________ b.) PNA No.: _____________________ b.) PNA No.: ________________________
Valid until: March 3, 2010________ Valid until: June 15, 2009__________________ Valid until: Valid until: ________________________
b.) PNA No.: 16223_______________ b.) PNA No.: _443__________________________ c.) ANSAP No.: _____________________ c.) ANSAP No.; ______________________
Valid until: 12/31/07____________ Valid until: _Lifetime______________________ Valid until: _______________________ Valid until: _______________________
Concurred by: Approved by:
(NAME OF CHIEF NURSE)____________ DR. HELEN C. ESTRELLA _____________

Signature over printed name of Chief Nurse Signature over printed name of Dean
Date Signed: ________________________ Date Signed: ________________________
Degree: _ ____________________ Degree: __MN,_DM___________________
a.) PRC No.: ________________________ a.) PRC No.: ‘0075238__________________
Valid until: ________________________ Valid until: June 19, 2011____________
b.) PNA No.: ________________________ b.) PNA No.: 2764_____________________
Valid until: ________________________ Valid until: Lifetime__________________
Valid until: _______________________ Valid until: 2007____________________
_______________________________________
NOTARY PUBLIC
Page _9_ of _10_

University of Cebu
Cebu City
Name of Student:
Name & Address of School: University of Cebu - Banilad Governor Cuenco Avenue, Banilad, Cebu
City________________________________________________________________________________________________________________
Accreditation Level (if any): _ ________________________________________________________ Year Granted: ____________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _______________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): _____________________________________________________________________________________________________________________________________________________________
V. Cord Dressing
Supervised by:
No Date Gender of
Case No. Name of Baby Name of Mother Age Name of Hospital Name & Signature of
. Performed Baby
Qualified C.I.
Mr. Mauro Allan P. Amparado,

1 275481 8/26/2005 Baby Boy Rosel Male May Rosel 22 Visayas Community Medical Center
RN, MAN

2 275511 8/27/2005 Baby Boy Dy Male Narcisa Dy 31 Visayas Community Medical Center
RN, MAN

3 03123 10/13/2005 Baby Girl Setias Female Erlinda Setias 43 Lapu-lapu District Hospital
RN, MAN

4 22327747 5/23/2006 Baby Girl Desucatan Female Janese Desucatan 23 Chong Hua Hospital
RN, MAN
02235443 Mr. Mauro Allan P. Amparado,

5 10/8/2006 Baby Girl Villanueva Female Mara C. Villanueva 24 Chong Hua Hospital
6 RN, MAN
Prepared by:
Name of Student Concurred by:

Concurred by:
Supervised by: Noted by: (NAME OF CHIEF NURSE) ____________
Signature over printed name of Chief Nurse (NAME OF CHIEF NURSE) __________
MRS. MERCY MILAGROS B. APUHIN MS. PILUCHI VICTORINA M. VILLEGAS_______ Date Signed: ________________________ Signature over printed name of Chief Nurse
Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Degree: ___ _____________________ Date Signed: ________________________
Date Signed: ____________________ Date Signed: _____________________________ a.) PRC No.:_ __________ Degree: __ _____________________
Degree: _MAN___________________ Degree: _________________________________ Valid until: a.) PRC No.: ________________________
a.) PRC No.: ‘0307204__________ __ a.) PRC No.: ‘0034689______________________ b.) PNA No.: ____________________ Valid until: ________________________
____ Valid until: June 15, 2009_________________ Valid until: ________________ b.) PNA No.: ________________________
Valid until: March 3, b.) PNA No.: _443_________________________ c.) ANSAP No.: ______________________ Valid until: ________________________
2010_____________ Valid until: _Lifetime_____________________ Valid until: _______________________ c.) ANSAP No.: ______________________
b.) PNA No.: 16223_____________________ Valid until: _______________________
Approved by:
DR. HELEN C. ESTRELLA______________

Signature over printed name of Dean
Date Signed: ________________________
Degree: _ MN, DM ___________________
a.) PRC No.: ‘0075238__________________
Valid until: June 19, 2008_____________
b.) PNA No.: 2764_____________________
Valid until: Lifetime__________________
c.) ADCPN No.: 154____________________
Valid until: 2007____________________
_______________________________________
NOTARY PUBLIC

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University of Cebu

College of Nursing – Banilad Campus

Modified Radical Rogelio G. Chong Hua Eileen Gail O.

Chong Hua Montzheimer C.

II. Minor Operations

Inverting Papilloma, Nasal

Excision of Mass, Visayas

Cauterization of Jose Rizalito C. Chong Hua Lorelei G. Angot,

Concurred by: Approved by:

(NAME OF CHIEF NURSE)_____________ DR. HELEN C. ESTRELLA ____________

III. Actual Deliveries

Pregnancy Uterine Full Term Normal Spontaneous Mr. Mauro Allan P.

Pregnancy Uterine Full Term Normal Spontaneous Mr. Mauro Allan P.

Concurred by: Concurred by: Approved by:

Mrs. Josifina A. Empaces___________ Mrs. Evelyn J. Monsanto_______________ Dr. Helen C.Estrella___________________

IV. Deliveries Assisted

Pregnancy Uterine Full Term Normal Spontaneous Mr. Mauro Allan P.

Pregnancy Uterine Full Term Normal Spontaneous Mr. Mauro Allan P.

Concurred by: Concurred by:

(NAME OF CHIEF NURSE)____________ DR. HELEN C. ESTRELLA _____________

Page _9_ of _10_

Mr. Mauro Allan P. Amparado,

Mr. Mauro Allan P. Amparado,

Mr. Mauro Allan P. Amparado,

Mr. Mauro Allan P. Amparado,

02235443 Mr. Mauro Allan P. Amparado,

Name of Student Concurred by:

DR. HELEN C. ESTRELLA______________

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