VELEZ COLLEGE
COLLEGE OF NURSING
F. Ramos Street, Cebu City
RECORD OF OPERATING ROOM CASES
NAME OF STUDENT:_____________________________________________ Accreditation Level (if any): PAASCU ACCREDITED LEVEL II
First Course if any: ________________________________________________ Y e a r G r a n t e d : _______________2001____________________
School Graduated From: _____________________________Year: __________ Date School/Program was Recognized:
Year of Admission in the BSN Program: ________________________________ April 12, 1955 (G.N.) No. 88 Year: 1955
Year Graduated (BSN Program): _____________________________________ June 4, 1973_ (B.S.N.) No. 145 Year: 1973
I. MAJOR OPERATIONS
DATE OF CASE TYPE OF NAME OF NAME OF NAME OF SIGNATURE OF
NAME OF DIAGNOSIS OPERATION
N OPERATI NO. ANESTHESIA SURGEON O.R. O.R. SCRUB
* HOSPIT
PATIENT PERFORMED
O ON SCRUB NURSE
AL
NURSE
1.
2.
3.
4.
5.
*C.V.G.H. – Cebu Velez General Hospital
PREPARED BY: ______________________________
Signature over Printed Name
SUPERVISED BY: NOTED BY: CONCURRED & APPROVED BY:
EMILIANO IAN II B. SUSON, BSN, RN, MAN MA. NONA A. VELEZ, BSN, RN, MN LILIOSA LUMBAB, RN, BSN, M.A., Ed.D.
Name of Faculty Clinical Coordinator Dean, College of Nursing
Date Signed:________________________ Date Signed:__________________________ Chief Nurse, Cebu Velez General Hospital
Date Signed:_____________________
Degree:___BSN, RN, MAN____________ BSN, RN, MN_______________
Degree:
PRC No. 0321033 Valid Until:_Nov. 2009 PRC No. 0142716 Valid Until: Renewed Feb. 2008 RN, BSN, M.A.in Nursing Educ./Adm., Ed.D.
PNA No. 65196____Valid Until: Dec. 2009 PNA No. 33895 Valid Until: Lifetime Membership PRC No. 0006670 Valid Until: Renewed March 2008
ADPCN No. 238 Valid Until: 2008_____
PNA No. 704_ Valid Until: Lifetime Membership
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement
pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
_________________________
Signature of Applicant
Subscribe and sworn to before me this ____________day of __________________ 2008, Philippines.
NOTARY PUBLIC

VELEZ COLLEGE
COLLEGE OF NURSING
F. Ramos Street, Cebu City
RECORD OF OPERATING ROOM CASES
NAME OF STUDENT:_______________________________________ Accreditation Level (if any): PAASCU ACCREDITED LEVEL II
First Course if any: ________________________________________________ Y e a r G r a n t e d : _______________2001____________________
School Graduated From: _____________________________Year: __________ Date School/Program was Recognized:
Year of Admission in the BSN Program: ________________________________ April 12, 1955 (G.N.) No. 88 Year: 1955
Year Graduated (BSN Program): _____________________________________ June 4, 1973_ (B.S.N.) No. 145 Year: 1973
II. MINOR OPERATIONS
DATE OF CASE TYPE OF NAME OF NAME OF NAME OF SIGNATURE OF
NAME OF DIAGNOSIS OPERATION
N OPERATI NO. ANESTHESIA SURGEON HOSPITA O.R. O.R. SCRUB
PATIENT PERFORMED
O ON L* SCRUB NURSE
NURSE
1.
2.
3.
4.
5.
*C.V.G.H. – Cebu Velez General Hospital
PREPARED BY: ______________________________
Signature over Printed Name
SUPERVISED BY: NOTED BY: CONCURRED & APPROVED BY:
EMILIANO IAN II B. SUSON, BSN, RN, MAN MA. NONA A. VELEZ, BSN, RN, MN LILIOSA LUMBAB, RN, BSN, M.A., Ed.D.
Name of Faculty Clinical Coordinator Dean, College of Nursing
Date Signed:________________________ Date Signed:__________________________ Chief Nurse, Cebu Velez General Hospital
Date Signed:_____________________
Degree:___BSN, RN, MAN____________ BSN, RN, MN_______________
Degree:
PRC No. 0321033 Valid Until:_Nov. 2009 PRC No. 0142716 Valid Until: Renewed Feb. 2008 RN, BSN, M.A.in Nursing Educ./Adm., Ed.D.
PNA No. 65196____Valid Until: Dec. 2009 PNA No. 33895 Valid Until: Lifetime Membership PRC No. 0006670 Valid Until: Renewed March 2008
ADPCN No. 238 Valid Until: 2007
PNA No. 704 Valid Until: Lifetime Membership
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete
statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
_________________________
Signature of Applicant
Subscribe and sworn to before me this ____________day of __________________ 2008, Philippines.
NOTARY PUBLIC

VELEZ COLLEGE
COLLEGE OF NURSING
F. Ramos Street, Cebu City
RECORD OF DELIVERY ROOM CASES
NAME OF STUDENT:____________________________________________ Accreditation Level (if any): PAASCU ACCREDITED LEVEL II
First Course if any: ________________________________________________ Y e a r G r a n t e d : _______________2001________________
School Graduated From: _____________________________Year: __________ Date School/Program was Recognized:
Year of Admission in the BSN Program: _______________________________ April 12, 1955 (G.N.) No. 88 Year: 1955
Year Graduated (BSN Program): _____________________________________ June 4, 1973_ (B.S.N.) No. 145 Year: 1973
III. ACTUAL DELIVERIES
SUPERVISED BY :
DATE OF TIME OF GENDER NAME OF TYPE OF
N CASE NO. DIAGNOSIS NAME OF MOTHER AGE NAME &
DELIVER DELIVERY OF BABY DELIVERY
* HOSPIT
O SIGNATURE OF
Y AL QUALIF I E D C.I.
1.
2.
3.
4.
5.
*C.V.G.H. – Cebu Velez General Hospital
PREPARED BY: ______________________________ SAMCH - St. Anthony Mother & Child Hospital
Signature over Printed Name
SUPERVISED BY: NOTED BY: CONCURRED BY: CONCURRED & APPROVED BY:
JOGI S. RIVAMONTE, BSN, RN, MN MA. CAROL R. KANGLEON, BSN, RN, MN ROSENIE F. CORONADO, RN, RM, MN LILIOSA LUMBAB, RN, BSN, M.A., Ed.D.
Name of Faculty Clinical Coordinator Chief Nurse, St.Anthony Mother & Child Hospital Dean, College of Nursing
Date Signed:___________________ Date signed:__ __________________________ Date signed:___________________ Chief Nurse, Cebu Velez General Hospital
Degree:__ _BSN, RN, MN _________ BSN, RN, RM, MN__ ______ Date Signed:_____________________
BSN, RN, MN
Degree: ___________ Degree:
PRC No. 0126394 _ Valid Until: Dec.31, 2010__ PRC No. RN: 0063068 Valid Until: April 24, 2009_ RN, BSN, M.A.in Nursing Educ./Adm., Ed.D.
PRC No. 0320684_ Valid Until: 04/24/2010_
PRC No. RM: 0048475 Valid Until: April 24, 2009 PRC No. 0006670 Valid Until: March 15, 2008
PNA No. _12851_Valid Until: Lifetime Membership
PNA No. 65195__Valid Until: 12/31/2008 PNA No. _6780 _Valid Until: _Lifetime Membership ADPCN No. 238 Valid Until: 2007
PNA No. 704 Valid Until: Lifetime Membership
ANSAP No._1476_Valid Until: Lifetime Membership
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement
pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
_________________________
Signature of Applicant
Subscribe and sworn to before me this ____________day of __________________ 2008, Philippines.
NOTARY PUBLIC

VELEZ COLLEGE
COLLEGE OF NURSING
F. Ramos Street, Cebu City
RECORD OF DELIVERY ROOM CASES
NAME OF STUDENT:____________________________________________ Accreditation Level (if any): PAASCU ACCREDITED LEVEL II
First Course if any: ________________________________________________ Y e a r G r a n t e d : _______________2001________________
School Graduated From: _____________________________Year: __________ Date School/Program was Recognized:
Year of Admission in the BSN Program: _______________________________ April 12, 1955 (G.N.) No. 88 Year: 1955
Year Graduated (BSN Program): _____________________________________ June 4, 1973 (B.S.N.) No. 145 Year: 1973
IV. DELIVERIES ASSISTED
SUPERVISED BY :
DATE OF TIME GENDER NAME OF TYPE OF
N CASE NO. DIAGNOSIS NAME OF PATIENT AGE NAME & SIGNATURE
DELIVER OF OF BABY HOSPITA DELIVER
O OF QUALIF I E D C.I.
Y DELIVE L* Y
RY
1.
2.
3.
4.
5.
*C.V.G.H. – Cebu Velez General Hospital
PREPARED BY: ______________________________ SAMCH - St. Anthony Mother & Child Hospital
Signature over Printed Name
SUPERVISED BY: NOTED BY: CONCURRED BY: CONCURRED & APPROVED BY:
JOGI S. RIVAMONTE, BSN, RN, MN MA. CAROL R. KANGLEON, BSN, RN, MN ROSENIE F. CORONADO, RN, RM, MN LILIOSA LUMBAB, RN, BSN, M.A., Ed.D.
Name of Faculty Clinical Coordinator Dean, College of Nursing
Chief Nurse, St.Anthony Mother & Child Hospital
Date Signed:___________________ Date signed:__ __________________________ Date signed:___________________ Chief Nurse, Cebu Velez General Hospital
Degree:__ _BSN, RN, MN _________ BSN, RN, RM, MN__ ______ Date Signed:_____________________
BSN, RN, MN
Degree: ___________ Degree:
PRC No. 0126394 _ Valid Until: Dec.31, 2010__ PRC No. RN: 0063068 Valid Until: April 24, 2009_ RN, BSN, M.A.in Nursing Educ./Adm., Ed.D.
PRC No. 0320684_ Valid Until: 04/24/2010_
PNA No. _12851_Valid Until: Lifetime Membership PRC No. RM: 0048475 Valid Until: April 24, 2009 PRC No. 0006670 Valid Until: March 15, 2008
PNA No. 65195__Valid Until: 12/31/2008 PNA No. _6780 _Valid Until: _Lifetime Membership ADPCN No. 238 Valid Until: 2007
PNA No. 704 Valid Until: Lifetime Membership
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement pursuant to
the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.
_________________________
Signature of Applicant

Subscribe and sworn to before me this ____________day of __________________ 2008, Philippines.
NOTARY PUBLIC
VELEZ COLLEGE
COLLEGE OF NURSING
F. Ramos Street, Cebu City
RECORD OF DELIVERY ROOM CASES
NAME OF STUDENT:_____________________________________________ Accreditation Level (if any): PAASCU ACCREDITED LEVEL II
First Course if any: ________________________________________________ Y e a r G r a n t e d : _______________2001________________
School Graduated From: _____________________________Year: __________ Date School/Program was Recognized:
Year of Admission in the BSN Program: _______________________________ April 12, 1955 (G.N.) No. 88 Year: 1955
Year Graduated (BSN Program): _____________________________________ June 4, 1973_ (B.S.N.) No. 145 Year: 1973
V. CORD DRESSING
SUPERVISED BY:
NAME OF
DATE GENDER
N CASE NO. NAME OF BABY NAME OF MOTHER AGE NAME & SIGNATURE OF
HOSPITA
PERFORME OF BABY
O QUALIF I E D C.I.
L*
D
1.
2.
3.
4.
5.
*C.V.G.H. – Cebu Velez General Hospital
PREPARED BY: ______________________________ SAMCH - St. Anthony Mother & Child Hospital
Signature over Printed Name
SUPERVISED BY: NOTED BY: CONCURRED BY: CONCURRED & APPROVED BY:
JOGI S. RIVAMONTE, BSN, RN, MN MA. CAROL R. KANGLEON, BSN, RN, MN ROSENIE F. CORONADO, RN, RM, MN LILIOSA LUMBAB, RN, BSN, M.A., Ed.D.
Name of Faculty Clinical Coordinator Dean, College of Nursing
Chief Nurse, St.Anthony Mother & Child Hospital
Date Signed:___________________ Date signed:__ __________________________ Date signed:___________________ Chief Nurse, Cebu Velez General Hospital
Degree:__ _BSN, RN, MN _________ BSN, RN, RM, MN__ ______ Date Signed:_____________________
BSN, RN, MN
Degree: ___________ Degree:
PRC No. 0126394 _ Valid Until: Dec.31, 2010__ PRC No. RN: 0063068 Valid Until: April 24, 2009_ RN, BSN, M.A.in Nursing Educ./Adm., Ed.D.
PRC No. 0320684_ Valid Until: 04/24/2010_
PNA No. _12851_Valid Until: Lifetime Membership PRC No. RM: 0048475 Valid Until: April 24, 2009 PRC No. 0006670 Valid Until: March 15, 2008
PNA No. 65195__Valid Until: 12/31/2008 PNA No. _6780 _Valid Until: _Lifetime Membership ADPCN No. 238 Valid Until: 2007
PNA No. 704 Valid Until: Lifetime Membership
I declare under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is a true, correct and complete statement pursuant
to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

_________________________
Signature of Applicant
Subscribe and sworn to before me this ____________day of __________________ 2008, Philippines.
NOTARY PUBLIC