LICEO DE CAGAYAN UNIVERSITY

College of Nursing
Rodolfo N. Pelaez Boulevard
Kauswagan, Cagayan de Oro City
School Code: 0835

Name of Student: Family Name, First Name, Middle Initials

Name and Address of School: Liceo de Cagayan University – Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
Recognition and Accreditation Level: PACUCOA – Level III Autonomous Level First Course (if any): (for second coursers only)
Year Granted: October 2008 November 2009 School Graduated from: N/A Year: N/A
Date when school was recognized: June 1972 Year of Admission in the BSN Program: June 2007
Year Graduated (BSN Program): March 2010

I. MAJOR OPERATIONS
Date of Case Name of Operation Performed Types of Name of Name of Name of Signature
No Operati No. Patient Diagnosis Anesthesi Surgeon Hospital Qualified OR of OR
. on a Scrub Nurse Scrub
Nurse
Blank
1
Blank
2
Blank
3
Blank
4
Blank
5

Prepared by:
Supervised by: Noted by: Concurred by: Approved by:
First Name M.I Family Name
Name and Signature of Student Full Name Full Name Full Name Full Name
Office Role Office Role Office Role Dean
Institution Institution Institution Institution
Date Signed: Date Signed: Date Signed: Date Signed:
_____________ _____________ _____________ _____________
Degree: Degree: Degree: Degree:
PRC No: PRC No: PRC No: PRC No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
PNA No: PNA No: PNA No: PNA No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
 LICEO DE CAGAYAN UNIVERSITY
College of Nursing
Rodolfo N. Pelaez Boulevard
Kauswagan, Cagayan de Oro City
School Code: 0835

Name of Student: Family Name, First Name, Middle Initials

Name and Address of School: Liceo de Cagayan University – Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
Recognition and Accreditation Level: PACUCOA – Level III Autonomous Level First Course (if any): (for second coursers only)
Year Granted: October 2008 November 2009 School Graduated from: N/A Year: N/A
Date when school was recognized: June 1972 Year of Admission in the BSN Program: June 2007
Year Graduated (BSN Program): March 2010

II. MINOR OPERATIONS

Date of Case Name of Operation Types of Name of Name of Name of OR Signature
No Operati No. Patient Diagnosis Performed Anesthesi Surgeon Hospital Scrub Nurse of OR
. on a Scrub
Nurse
1 Blank

Blank
2
Blank
3
4 Blank

Blank
5

Prepared by:
Supervised by: Noted by: Concurred by: Approved by:
First Name M.I Family Name
Name and Signature of Student Full Name Full Name Full Name Full Name
Office Role Office Role Office Role Dean
Institution Institution Institution Institution
Date Signed: Date Signed: Date Signed: Date Signed:
_____________ _____________ _____________ _____________
Degree: Degree: Degree: Degree:
PRC No: PRC No: PRC No: PRC No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
PNA No: PNA No: PNA No: PNA No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
 LICEO DE CAGAYAN UNIVERSITY
College of Nursing
Rodolfo N. Pelaez Boulevard
Kauswagan, Cagayan de Oro City
School Code: 0835

Name of Student: Family Name, First Name, Middle Initials

Name and Address of School: Liceo de Cagayan University – Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
Recognition and Accreditation Level: PACUCOA – Level III Autonomous Level First Course (if any): (for second coursers only)
Year Granted: October 2008 November 2009 School Graduated from: N/A Year: N/A
Date when school was recognized: June 1972 Year of Admission in the BSN Program: June 2007
Year Graduated (BSN Program): March 2010

III. HANDLED DELIVERIES

Time Gend
Name Date of Name and Signature of
Case of er Name of Type
N Diagnosis of Ag Deliver Qualified DR Clinical
No. Delive of Hospital of Delivery
o. Mother e y Instructor
ry Baby
1

Prepared by:
Supervised by: Noted by: Concurred by: Approved by:
First Name M.I Family Name
Name and Signature of Student Full Name Full Name Full Name Full Name
Office Role Office Role Office Role Dean
Institution Institution Institution Institution
Date Signed: Date Signed: Date Signed: Date Signed:
_____________ _____________ _____________ _____________
Degree: Degree: Degree: Degree:
PRC No: PRC No: PRC No: PRC No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
PNA No: PNA No: PNA No: PNA No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
 LICEO DE CAGAYAN UNIVERSITY
College of Nursing
Rodolfo N. Pelaez Boulevard
Kauswagan, Cagayan de Oro City
School Code: 0835

Name of Student: Family Name, First Name, Middle Initials

Name and Address of School: Liceo de Cagayan University – Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
Recognition and Accreditation Level: PACUCOA – Level III Autonomous Level First Course (if any): (for second coursers only)
Year Granted: October 2008 November 2009 School Graduated from: N/A Year: N/A
Date when school was recognized: June 1972 Year of Admission in the BSN Program: June 2007
Year Graduated (BSN Program): March 2010

IV. ASSISTED DELIVERIES

Time Gend
Name Name and Signature of
Case Date of of er Name of Types
N Diagnosis of Ag Qualified DR Clinical
No. Delivery Deliv of Hospital of Delivery
o. Mother e Instructor
ery Baby
1

2
3

Prepared by:
Supervised by: Noted by: Concurred by: Approved by:
First Name M.I Family Name
Name and Signature of Student Full Name Full Name Full Name Full Name
Office Role Office Role Office Role Dean
Institution Institution Institution Institution
Date Signed: Date Signed: Date Signed: Date Signed:
_____________ _____________ _____________ _____________
Degree: Degree: Degree: Degree:
PRC No: PRC No: PRC No: PRC No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
PNA No: PNA No: PNA No: PNA No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
 LICEO DE CAGAYAN UNIVERSITY
College of Nursing
Rodolfo N. Pelaez Boulevard
Kauswagan, Cagayan de Oro City
School Code: 0835

Name of Student: Family Name, First Name, Middle Initials

Name and Address of School: Liceo de Cagayan University – Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
Recognition and Accreditation Level: PACUCOA – Level III Autonomous Level First Course (if any): (for second coursers only)
Year Granted: October 2008 November 2009 School Graduated from: N/A Year: N/A
Date when school was recognized: June 1972 Year of Admission in the BSN Program: June 2007
Year Graduated (BSN Program): March 2010

V. IMMEDIATE NEWBORN CARE

Name and Signature of
Case Date Name of Gender of Name of Name of
Age Type of Delivery Qualified
No. No. Performed Baby Baby Mother Hospital
DR Clinical Instructor

Prepared by:
Supervised by: Noted by: Concurred by: Approved by:
First Name M.I Family Name
Name and Signature of Student Full Name Full Name Full Name Full Name
Office Role Office Role Office Role Dean
Institution Institution Institution Institution
Date Signed: Date Signed: Date Signed: Date Signed:
_____________ _____________ _____________ _____________
Degree: Degree: Degree: Degree:
PRC No: PRC No: PRC No: PRC No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date
PNA No: PNA No: PNA No: PNA No:
Valid Until: Date Valid Until: Date Valid Until: Date Valid Until: Date