Republic of the Philippines

Nueva Ecija University of Science and Technology

Cabanatuan City

College of Nursing

Name of Student: Shinichi Kudou

Name and Address of School: Nueva Ecija University of Science and Technology

Cabanatuan City, Nueva Ecija 3100

Accreditation Level (If Any): Not Applicable

Date When School/Program Was Recognized: December 2, 2003 Board Resolution 96-A Series 2003

School Graduated (If Any): Not Applicable

Year of Admission in Bachelor of Science in Nursing Program: 2008

Year Graduated: 2011

I. Major Operation
No. Date of Operation Case Number Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital

Prepared by: Supervised by: Noted by: Concurred by: Noted by:

Shinichi Kudou Dante L. Florentino Jr. Luzviminda I. Dallo Bienvenida R. Capule Eppie DC. Bugarin

Name of Student Clinical Instructor RLE Coordinator College of Nursing Chief Nurse, Paulino J. Garcia Memorial Dean, College of Nursing
Research and Medical Center
Degree/s: Registered Nurse Degree/s: Bachelor of Science in Nursing Nueva Ecija University of Science and
Degree/s: Registered Nurse Technology
27 units Master of Registered Nurse
Master of Arts in Nursing Degree/s: Registered Midwife
Art in Nursing Master of Arts in Nursing
PRC Number: 0028001 Registered Nurse
PRC Number: 04001733 PRC Number: 0084572
Valid Until: March 22, 2011 Master of Arts in Nursing
Valid Until: November 27, 2012 Valid Until: August 19, 2011
PNA Number: 07629 PRC Number: 0085974
PNA Number: 2011-060597 PNA Number: 19755
Valid Until: Lifetime Member Valid Until: April 3, 2011
Valid Until: October 31, 2011 Valid Until: Lifetime Member
Date Signed: ____________ PNA Number: 17977
OR NAP Number: NCR-0016412 Date Signed: ______________
Valid Until: December 2010
Expiration: July 2011
Date Signed: _______________
 Republic of the Philippines

Nueva Ecija University of Science and Technology

Cabanatuan City

College of Nursing

Name of Student: Shinichi Kudou

Name and Address of School: Nueva Ecija University of Science and Technology

Cabanatuan City, Nueva Ecija 3100

Accreditation Level (If Any): Not Applicable

Date When School/Program Was Recognized: December 2, 2003 Board Resolution 96-A Series 2003

School Graduated (If Any): Not Applicable

Year of Admission in Bachelor of Science in Nursing Program: 2008

Year Graduated: 2011

II. Minor Operation

No. Date of Operation Case Number Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital

Prepared by: Supervised by: Noted by: Concurred by: Noted by:

Shinichi Kudou Dante L. Florentino Jr. Luzviminda I. Dallo Ms. Alma Grace Cayme Eppie DC. Bugarin

Name of Student Clinical Instructor RLE Coordinator College of Nursing Municipal Health Nurse Dean, College of Nursing

Degree/s: Registered Nurse Degree/s: Bachelor of Science in Nursing Degree/s: Bachelor of Science in Nursing Nueva Ecija University of Science and
Technology
27 units Master of Registered Nurse Registered Nurse
Degree/s: Registered Midwife
Art in Nursing Master of Arts in Nursing 18 units Master of
Registered Nurse
PRC No.: 04001733 PRC Number: 0084572 Art in Nursing
Master of Arts in Nursing
Valid Until: November 27, 2012 Valid Until: August 19, 2011 PRC No.: 0181609
PRC Number: 0085974
PNA No.: 2011-060597 PNA No.: 19755 Valid Until: February 17, 2012
Valid Until: April 3, 2011
Valid Until: October 31, 2011 Valid Until: Lifetime Member PNA No.: 039802
PNA Number: 17977
OR NAP No.: NCR-0016412 Date Signed: ______________ Valid Until: December 31, 2010
Valid Until: December 2010
Expiration: July 2011 Date Signed: __________________
Date Signed: _______________
 Republic of the Philippines

Nueva Ecija University of Science and Technology

Cabanatuan City

College of Nursing

Name of Student: Shinichi Kudou

Name and Address of School: Nueva Ecija University of Science and Technology

Cabanatuan City, Nueva Ecija 3100

Accreditation Level (If Any): Not Applicable

Date When School/Program Was Recognized: December 2, 2003 Board Resolution 96-A Series 2003

School Graduated (If Any): Not Applicable

Year of Admission in Bachelor of Science in Nursing Program: 2008

Year Graduated: 2011

III. Actual Deliveries

No. Case Number Diagnosis Name of Mother Age Date of Delivery Time of Delivery Gender of Baby Name of Hospital Type of Delivery

Prepared by: Supervised by: Noted by: Concurred by: Noted by:

Shinichi Kudou Dante L. Florentino Jr. Luzviminda I. Dallo Ms. Alma Grace Cayme Eppie DC. Bugarin

Name of Student Clinical Instructor RLE Coordinator College of Nursing Municipal Health Nurse Dean, College of Nursing

Degree/s: Registered Nurse Degree/s: Bachelor of Science in Nursing Degree/s: Bachelor of Science in Nursing Nueva Ecija University of Science and
Technology
27 units Master of Registered Nurse Registered Nurse
Degree/s: Registered Midwife
Art in Nursing Master of Arts in Nursing 18 units Master of
Registered Nurse
PRC No.: 04001733 PRC Number: 0084572 Art in Nursing
Master of Arts in Nursing
Valid Until: November 27, 2012 Valid Until: August 19, 2011 PRC No.: 0181609
PRC Number: 0085974
PNA No.: 2011-060597 PNA No.: 19755 Valid Until: February 17, 2012
Valid Until: April 3, 2011
Valid Until: October 31, 2011 Valid Until: Lifetime Member PNA No.: 039802
PNA Number: 17977
OR NAP No.: NCR-0016412 Date Signed: ______________ Valid Until: December 31, 2010
Valid Until: December 2010
Expiration: July 2011 Date Signed: __________________
Date Signed: _______________
 Republic of the Philippines

Nueva Ecija University of Science and Technology

Cabanatuan City

College of Nursing

Name of Student: Shinichi Kudou

Name and Address of School: Nueva Ecija University of Science and Technology

Cabanatuan City, Nueva Ecija 3100

Accreditation Level (If Any): Not Applicable

Date When School/Program Was Recognized: December 2, 2003 Board Resolution 96-A Series 2003

School Graduated (If Any): Not Applicable

Year of Admission in Bachelor of Science in Nursing Program: 2008

Year Graduated: 2011

IV. Assisted Deliveries

No. Case Number Diagnosis Name of Mother Age Date of Delivery Gender of Baby Name of Hospital Type of Delivery

Prepared by: Supervised by: Noted by: Concurred by: Noted by:

Shinichi Kudou Dante L. Florentino Jr. Luzviminda I. Dallo Ms. Alma Grace Cayme Eppie DC. Bugarin

Name of Student Degree/s: Registered Nurse RLE Coordinator College of Nursing Municipal Health Nurse Dean, College of Nursing

27 units Master of Degree/s: Bachelor of Science in Nursing Degree/s: Bachelor of Science in Nursing Nueva Ecija University of Science and
Technology
Art in Nursing Registered Nurse Registered Nurse
Degree/s: Registered Midwife
PRC No.: 04001733 Master of Arts in Nursing 18 units Master of
Registered Nurse
Valid Until: November 27, 2012 PRC Number: 0084572 Art in Nursing
Master of Arts in Nursing
PNA No.: 2011-060597 Valid Until: August 19, 2011 PRC No.: 0181609
PRC Number: 0085974
Valid Until: October 31, 2011 PNA No.: 19755 Valid Until: February 17, 2012
Valid Until: April 3, 2011
OR NAP No.: NCR-0016412 Valid Until: Lifetime Member PNA No.: 039802
PNA Number: 17977
Expiration: July 2011 Date Signed: ______________ Valid Until: December 31, 2010
Valid Until: December 2010
Date Signed: _______________ Date Signed: __________________
Date Signed: _______________
 Nueva Ecija University of Science and Technology

Cabanatuan City

Republic of the Philippines

College of Nursing

Name of Student: Shinichi Kudou

Name and Address of School: Nueva Ecija University of Science and Technology

Cabanatuan City, Nueva Ecija 3100

Accreditation Level (If Any): Not Applicable

Date When School/Program Was Recognized: December 2, 2003 Board Resolution 96-A Series 2003

School Graduated (If Any): Not Applicable

Year of Admission in Bachelor of Science in Nursing Program: 2008

Year Graduated: 2011

V. Cord Dressing
No. Case Number Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital

Prepared by: Supervised by: Noted by: Concurred by: Noted by:

Dante L. Florentino Jr. Luzviminda I. Dallo Bienvenida R. Capule Eppie DC. Bugarin
Shinichi Kudou

Clinical Instructor RLE Coordinator College of Nursing Chief Nurse, Paulino J. Garcia Memorial Dean, College of Nursing
Name of Student Research and Medical Center
Degree/s: Registered Nurse Degree/s: Bachelor of Science in Nursing Nueva Ecija University of Science and
Degree/s: Registered Nurse Technology
27 units Master of Registered Nurse
Master of Arts in Nursing Degree/s: Registered Midwife
Art in Nursing Master of Arts in Nursing
PRC Number: 0028001 Registered Nurse
PRC Number: 04001733 PRC Number: 0084572
Valid Until: March 22, 2011 Master of Arts in Nursing
Valid Until: November 27, 2012 Valid Until: August 19, 2011
PNA Number: 07629 PRC Number: 0085974
PNA Number: 2011-060597 PNA Number: 19755
Valid Until: Lifetime Member Valid Until: April 3, 2011
Valid Until: October 31, 2011 Valid Until: Lifetime Member
Date Signed: ____________ PNA Number: 17977
OR NAP Number: NCR-0016412 Date Signed: ______________
Valid Until: December 2010
Expiration: July 2011
Date Signed: _______________