Major OR Scrubs

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West Visayas State University La Paz, Iloilo City Name of Student: Date School/Program was Recognized: April 21, 1977 Accreditation Level: Level III AACCUP (2007) First Course (if any): N/A School Graduated from: N/A Year of Admission in the BSN Program: 2008 Year Graduated from the BSN Program: 2012 I. MAJOR OPERATIONS No. Time Started Time Ended Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Year: N/A

Prepared by:

Supervised by:

Noted by:

Approved by:

SHEILA P. BELIRAN, M.A.N. Associate Dean/Clinical Coordinator Date Signed: _______________ CTC Number: Date Place : : Units Earned Beyond BSN: Date Signed: _______________ Degree: Bachelor of Science in Nursing Date Signed: _______________ Degree: Master of Arts in Nursing

ROSANA GRACE B. BELO, Ed. D. OIC - DEAN Date Signed: _______________ Degree: Master in Public Health, Master in Nursing, Doctor of Education

a)     PRC No. : Valid Until: b)     PNA No. : Valid Until:

a) b)

PRC No. : 0277468 Valid Until: September 4, 2012 PNA No. : 022997 Valid Until: October 31, 2010

a) b)

PRC No. : 0084964 Valid Until: October 22, 2012 PNA No. : 06-IL-0487-1 Valid Until: Life

Visayas State University La Paz, Iloilo City Year: N/A

AJOR OPERATIONS Name of Surgeon Name of Hospital

Concurred by:

Chief Nurse Date Signed: _______________ Degree:

a)    PRC No.

:

Valid Until: b)     PNA No. : Valid Until:

West Visayas State University La Paz, Iloilo City Name of Student: Date School/Program was Recognized: April 21, 1977 Accreditation Level: Level III AACCUP (2007) First Course (if any): N/A School Graduated from: N/A Year of Admission in the BSN Program: 2006 Year Graduated from the BSN Program: 2010 I. MAJOR OPERATIONS No. Time Started Time Ended Date of Operation Case No. Name of Patient Operation Performed

Prepared by:

Supervised by:

Noted by:

Approved by:

SHEILA P. BELIRAN, M.A.N. Associate Dean/Clinical Coordinator Date Signed: _______________ CTC Number: Date Place : : Units Earned Beyond BSN: Date Signed: _______________ Degree: Bachelor of Science in Nursing Date Signed: _______________ Degree: Master of Arts in Nursing

ROSANA GRACE B. BE OIC - DEAN

Date Signed: _________

Degree: Master in Public Nursing, Doctor of Educa

a)     PRC No. : Valid Until: b)     PNA No. : Valid Until:

a) b)

PRC No. : 0277468 Valid Until: September 4, 2012 PNA No. : 022997 Valid Until: October 31, 2010

a) b)

PRC No. : 0084964 Valid Until: October Valid Until: Life

PNA No. : 06-IL-04

ayas State University Paz, Iloilo City Year: N/A

OR OPERATIONS Type of Anesthesia Name of Surgeon Name of Hospital

Concurred by:

ROSANA GRACE B. BELO, Ed. D. Chief Nurse Date Signed: _______________ Degree: Master in Public Health, Master in Nursing, Doctor of Education Date Signed: _______________ Degree:

a) b)

PRC No. : 0084964 Valid Until: October 22, 2012 PNA No. : 06-IL-0487-1 Valid Until: Life

a)    PRC No.

:

Valid Until: b)     PNA No. : Valid Until: Life

West Visayas State University La Paz, Iloilo City Name of Student: Date School/Program was Recognized: April 21, 1977 Accreditation Level: Level III AACCUP (2007) First Course (if any): N/A School Graduated from: N/A Year of Admission in the BSN Program: 2008 Year Graduated from the BSN Program: 2012 I. MAJOR OPERATIONS No. Time Started Time Ended Date of Operation Case No. Name of Patient Operation Performed Type of Anesthesia Name of Surgeon Year: N/A

Prepared by:

Supervised by:

Noted by:

Approved by:

SHEILA P. BELIRAN, M.A.N. Associate Dean/Clinical Coordinator Date Signed: _______________ CTC Number: Date Place : : Units Earned Beyond BSN: Date Signed: _______________ Degree: Bachelor of Science in Nursing Date Signed: _______________ Degree: Master of Arts in Nursing

ROSANA GRACE B. BELO, Ed. D. OIC - DEAN Date Signed: _______________ Degree: Master in Public Health, Master in Nursing, Doctor of Education

a)     PRC No. : Valid Until: b)     PNA No. : Valid Until:

a) b)

PRC No. : 0277468 Valid Until: September 4, 2012 PNA No. : 022997 Valid Until: October 31, 2010

a) b)

PRC No. : 0084964 Valid Until: October 22, 2012 PNA No. : 06-IL-0487-1 Valid Until: Life

isayas State University La Paz, Iloilo City Year: N/A

AJOR OPERATIONS Name of Surgeon Name of Hospital

Concurred by:

Chief Nurse Date Signed: _______________ Degree:

a)    PRC No.

:

Valid Until: b)     PNA No. : Valid Until:

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