UNIVERSITY OF PANGASINAN

COLLEGE OF NURSING
DAGUPAN CITY
University Seal

NAME OF STUDENT: SANTOS, Paul Christian Padama First Course (if any):
Name and Address of School: University of Pangasinan School graduated from:
Arellano St., Dagupan City Year:
Accreditation Level (if any): Level I (PACUCOA) Year Granted: March 05, 2007 Year of admission in the BSN Program: June 2007
Date School / Program was recognized: May 19, 1976 Number: 44 Year: 1976 Year graduated from BSN Program: 2010

II. MINOR OPERATIONS

REMOVE “S” IF ONLY CONTAINS 1 CASE
TIME OF NAME OF PATIENT
DATE of OPERATION OPERATION TYPE of NAME of NAME of Name and Signature of Qualified
No.
OPERATION STARTED- DIAGNOSIS
CASE NO. PERFORMED ANESTHESIA SURGEON HOSPITAL Clinical Instructor
ENDED
Local,
1-9 Never
Regional, ALLCAPS
Put 0 if 1-9 Put 0 Just
1 No abbreviations No abbreviations General, Dr. HOSPITAL
May 05 type 8:00
Intravenous ACRONYM
AM/PM I-AM D. CI, RN [PUT “MRS.” IF Female and Married]
Sedation
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2 unfilled unfilled
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unfilled unfilled unfilled
[3-5 CASES logo size = 1Peso Coin]
Remove if unfilled [1-2 CASES logo size = 5Peso Coin] and consume the SPACE
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3 Remove if unfilled
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4 Remove if unfilled
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5 Remove if unfilled
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LEGEND: HOSPITAL’S ACRONYM = Hospital’s Complete Name (Level) [Bold Letters Here]

Prepared by: Concurred by:

PAUL CHRISTIAN P. SANTOS

Student _____,Chief Nurse
Date Signed:
Degree:
a). PRC No.: Valid Until:
b). PNA No.: Valid Until:
c). ANSAP No.: Valid Until:

Supervised by: Noted by: Approved by:

ZENAIDA M. BAUTISTA MELANIA C. CENON

Clinical Instructor Clinical Coordinator Dean
Date Signed: Date Signed: Date Signed:
Degree: Degree: BSN-RN, MAN Degree: BSN-RN, MAN, MAEd, PhD
a). PRC No.: Valid Until: a). PRC No.: 0133422 Valid Until: July 27, 2011 a). PRC No.: 0100236 Valid Until: January 06, 2012
b). PNA No.: Valid Until: b). PNA No.: 029069 Valid Until: December 31, 2009 b). PNA No.: 17978 Valid Until: Lifetime Member
c). ANSAP No.: 09-0054 Valid Until: December 31, 2009 c). ADPCN No.: 0185 Valid Until: December 31, 2009
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