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Ateneo de Zamboanga University
COLLEGE OF NURSING
Zamboanga City
Prepared by: FAMI, FIRST SECOND MIDDLE
Name and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga City
Recognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013
Date When School Program was recognized: CHED Memorandun No.1 series of 2005
First Course: Not applicable School Graduated From: Ateneo de Zamboanga University
Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year: Not Applicable
Year Graduated (BSN Program): March 2011
___________________________
NAME OF STUDENT
MAJOR OPERATION
Name and Name and
No. Date of Case No. Name of Patient Diagnosis Operation Anesthesia Name of Name of Signature of Signature of
Operation Performed Surgeon Hospital Scrub Nurse Qualified CI
Noted by: Concurred by:

Flor P. San Luis, RN, MN Evelyn Tindick-Monsanto, R.N., MEd., M.N.
Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Chief Nurse, Zamboanga City Medical Center
Highest Nursing Degree Earned Bachelor of Science in Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing
Master in Nursing Master in Education
Master in Nursing
Date signed: Date signed:
PRC I.D. No. 0062360 Valid Until : January 29, 2011 PRC I.D. No. 0063627 Valid until: December 12, 2012
PNA No. 017407 Valid Until : November 12, 2010 PNA No. 2927 Valid until: Life Member
ANSAP I.D. No. 006547 Valid Until: January 3, 2012 ANSAP No. 0381 Valid until: Life Member
Approved by:
Maria Lorna Bello-Paber, R.N., M.A.N.

Dean, Ateneo de Zamboanga University, College of Nursing
Highest Nursing Degree Earned Bachelor of Science in Nursing
Master of Arts in Nursing
Date signed:
PRC No. 0059150 Valid Until : September 15, 2010
PNA No. 6141 Valid Until : Lifetime Member
ADPCN No. 0655 Valid Until : December 31, 2010
Ateneo de Zamboanga University ODC Form 1
COLLEGE OF NURSING O.R. SCRUB From
La Purisima Street, Zamboanga City Major
CHED Memorandun No.1 series of 2005
Surgical Scrub in _______________________________________
Hospital, Municipality/City/Province
Prepared by:
Name of Student: _ _______________________________________________________ Signature of Student:
________________________________________________________________
Patient’s Name SUPERVISED BY:

Date Performed and Time Started Case Number PROCEDURE PERFORMED O.R. NURSE ON DUTY CLINICAL INSTRUCTOR
(NAME ONLY) NAME AND SIGNATURE

Master in Nursing
PRC I.D. No. 0062360 Valid Until : January 29, 2011
Approved by:

Date signed:
COLLEGE OF NURSING
Zamboanga City

___________________________
NAME OF STUDENT
MINOR OPERATION
Name and Name and
No. Date of Case No. Name of Patient Diagnosis Operation Anesthesia Name of Name of Signature of Signature of
Operation Performed Surgeon Hospital Scrub Nurse Qualified CI

Master in Nursing
Approved by:

Date signed:
COLLEGE OF NURSING O.R. SCRUB From
La Purisima Street, Zamboanga City Minor
Prepared by:
Name of Student: _____________________________________________ _____________ Signature of Student: ________________________________________________________

(NAME ONLY) NAME AND SIGNATURE

Master in Nursing
Approved by:

Date signed:
COLLEGE OF NURSING
Zamboanga City

___________________________
NAME OF STUDENT
ACTUAL DELIVERIES
Name & Siganture of
No. Csae No. Diagnosis Name of Patient Age Date of Delivery Time of Gender of Name of Hospital Type of Delivery Qualified C.I.
Delivery the Baby

Master in Nursing
Approved by:

Date signed:
COLLEGE OF NURSING ACTUAL DELIVERY
La Purisima Street, Zamboanga City FORM
Prepared by:
Name of Student: _ ___________________ _______________________________ Signature of Student: ________________________________________________________________

(not applicable for Birthing/lying- (NAME ONLY) NAME AND SIGNATURE
in Clinics/Homes)

Master in Nursing
Approved by:

Date signed:
COLLEGE OF NURSING
Zamboanga City

___________________________
NAME OF STUDENT
DELIVERIES ASSISTED
Name & Siganture of
No. Csae No. Diagnosis Name of Patient Age Date of Delivery Time of Gender of Name of Hospital Type of Delivery Qualified C.I.
Delivery the Baby

Master in Nursing
Approved by:

Date signed:
COLLEGE OF NURSING D.R. ASSIST FORM
La Purisima Street, Zamboanga City
Prepared by:
Name of Student: _ _______________________ _______________________________ Signature of Student: ________________________________________________________________

in Clinics/Homes)

Master in Nursing
Approved by:

Date signed:
COLLEGE OF NURSING
Zamboanga City

___________________________
NAME OF STUDENT
CORD DRESSING
No. Csae No. Date Performed Name of the Baby Gender of Name of the Mother Age of the Name of Hospital Name & Siganture of
the Baby Mother Qualified C.I.

Master in Nursing
Approved by:

Date signed:

COLLEGE OF NURSING D.R. CORD CARE
La Purisima Street, Zamboanga City FORM
Prepared by:
Name of Student: _ _____________________________________________________ Signature of Student: ________________________________________________________________

in Clinics/Homes)

Master in Nursing
Approved by:

Date signed:
PRC NUMBERS:
For Zamboanga City Medical Center
Flor P. San Luis, RN, MN EVELYN TINDICK-MONSANTO, RN, Med, MN
Clinical Coordinator, ADZU, College of Nursing Chief Nurse, Zambonaga City Medical Center
Highest Nursing Degree Earned: Bachelor of Science in Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing
Master in Nursing
Date & TIME document is signed: ______________ Time: ___________ Date & TIME document is signed: ______________ Time: ______
PRC I.D. No: 0062360 Valid until: January 29, 2011 PRC I.D. No. 0063627 ValidUntil::December 12, 2009
PNA No. 017407 Valid Until: December 31, 2010 PNA No. 2927 Valid Until: Life Member
ANSAP No. : 0381 Valid Until: Life Member
Approved by:
Maria Lorna Bello- Paber, RN, MAN
Dean, ADZU College of Nursing
PRC No.: 0069150 Valid Until: September 15, 2010
PNA No. 6141 Valid Until: Lifetime Member
ADPCN No. 0655 Valid Until: December 31, 2009
For Ciudad Medical Zamboanga

Ma. Lourdes Concepcion-Follero, RN, MN Celita P. Calma, RN, MAN
Clinical Coordinator, ADZU, College of Nursing Chief Nurse, Ciudad Medical Zamboanga
Master in Nursing Master Of Arts in Nursing
Date & TIME document is signed: ____________________ Time: _____ Date & TIME document is signed: ______________ Time: ______
PRC I.D. N0: 0115066 Valid until_December 06, 2011 PRC I.D. No. 069666 ValidUntil::March 9, 2012
PNA No. 016740 Valid Until: December 31, 2009 PNA No. 18799 Valid Until: Lifetime Member
ANSAP No. : 01038 Valid Until: December 31, 2009
Approved by:
For Zamboanga Doctors Hospital

Ma. Lourdes Concepcion-Follero, RN, MN Maria Bella M. Tandoc, RN, MAN
Clinical Coordinator, ADZU, College of Nursing Chief Nurse, Zamboanga Doctors Hospital
Master in Nursing Master of Arts in Nursing
Date & TIME document is signed: ____________________ Time: ___________ Date & TIME document is signed: ______________ Time: ______
PRC I.D. No. 0115066 Valid until_December 06, 2011 PRC I.D. No. 0041245 ValidUntil::February 04, 2010
ANSAP No. : Valid Until: December 31, 2009
Approved by:
PRC No.: 0069150 Valid Until: Lifetime
PNA No. 6141 Valid Until: Lifetime
For Western Mindanao Medical Center

Ma. Lourdes Concepcion-Follero, RN, MN Ma. Dolores B. Pacatang, RN
Clinical Coordinator, ADZU, College of Nursing Chief Nurse, Western Mindanao Medical Center
Master in Nursing
PRC I.D. No. 0115066 Valid until_December 06, 2011 PRC I.D. No. 074214 ValidUntil::February 2, 2011
ANSAP No. : 02629 Valid Until: December 31, 2009
Approved by:
For Zamboanga Puericulture Lying-In Maternnity Hospital

Ma. Lourdes Concepcion-Follero, RN, MN Ma. Theresa Geraldine Pioquinto, RN
Clinical Coordinator, ADZU, College of Nursing Chief Nurse, ZPMH
Master in Nursing
PRC I.D. No. . 0115066 Valid until_December 06, 2011 PRC I.D. No. 0177945 ValidUntil::October 11, 2011
PNA No. 016740 Valid Until: December 31, 2009 PNA No. 016531 Valid Until: December 31, 2009
Approved by:
Maria Lorna Bello-Paber, RN, MAN
For DOS
Noted by:
Ma. Lourdes Concepcion-Follero, RN, MN
Clinical Coordinator, ADZU, College of Nursing
Highest Nursing Degree Earned: Bachelor of Science in Nursing
Master in Nursing
Date & TIME document is signed: ____________________ Time: ___________
PRC I.D. No. 0115066 Valid until_December 06, 2011
PNA No. 016740 Valid Until: December 31, 2 009
Approved by:

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Ateneo de Zamboanga University

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Patient’s Name SUPERVISED BY:

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Prepared by: FAMI, FIRST SECOND MIDDLE

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Patient’s Name SUPERVISED BY:

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Prepared by: FAMI, FIRST SECOND MIDDLE

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Patient’s Name SUPERVISED BY:

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Prepared by: FAMI, FIRST SECOND MIDDLE

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Patient’s Name SUPERVISED BY:

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Prepared by: FAMI, FIRST SECOND MIDDLE

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Ateneo de Zamboanga University ODC Form 5

Patient’s Name SUPERVISED BY:

Noted by: Concurred by:

Maria Lorna Bello-Paber, R.N., M.A.N.

For Ciudad Medical Zamboanga

Noted by: Concurred by:

For Zamboanga Doctors Hospital

For Western Mindanao Medical Center

Noted by: Concurred by:

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