St.

Scholastica's College of Health Sciences

Sta. Cruz Street, Tacloban City 6500
Tel No. 325-2188 Local 201

Name of Student: CALONING, NICO LORENZO MENDOZA________________________________________________________________________________________________________________________

Name & Address of School: ST. SCHOLASTICA'S COLLEGE OF HEALTH SCIENCES Sta. Cruz St. Tacloban City
Accreditation Level: (if any) None Year Granted: None
Date School/Program was Recognized: April 11, 2003 Number (GR): 07 Year: 2003
First Course (if any): None School Graduated From: None Year: N/A
Year of Admission in the Bachelor of Science in Nursing Program: 2006
Year Graduated (BSN Program): 2010

Prepared by: CALONING, NICO LORENZO MENDOZA

Signature over printed name

IV. DELIVERIES ASSISTED

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

1 85-76-48 Normal spontaneous vaginal delivery to a live Pecho, 21 years old December 20, 6:08 pm Male Ormoc Normal Mrs. Priscilla V. Ventula, RN, MAN
baby boy in cephalic presentation with weight 3.5 Wendelyn 2008 District Spontaneous Date Signed: _______
kilograms with episiotomy, normal. Hospital Vaginal Degree: BSN, RN, MAN____________
Delivery a) PRC No:_0125185_______________
Valid Until: _05-28-2011____________
b) PNA No.:_078159________________
Valid Until: _December 2010_________

2 43-69-44 Pregnancy Uterine Full Term, Premature rupture Fabi, Charlyn 36 years old February 05, 6:24 pm Female Eastern Normal Mrs. Azucena T. Abit, RN, MAN
of membrane for 10 hours, delivered by 2010 Visayas Spontaneous Date Signed: _
spontaneous vaginal delivery to a live baby girl, Regional Vaginal Degree: BSN, RN, MAN______
APGAR score-9, clear amniotic fluid, birth weight- Medical Delivery a) PRC No:_0181954________
2,900grams, birth length-49centimeters, Gravida 3 Center Valid Until: _03-27-2013______
Para 3 (3003) b) PNA No.:_078140_________
Valid Until: __December 2010_

3 45-59-89 Pregnancy Uterine Full Term, delivered by Asuar, Madelyn 32 years old February 06, 7:36 pm Female Eastern Normal Mrs. Azucena T. Abit, RN, MAN
spontaneous vaginal delivery to a live baby girl, Encina 2010 Visayas Spontaneous Date Signed: _
APGAR score-9, clear amniotic fluid, birth weight Regional Vaginal Degree: BSN, RN, MAN______
2,700 grams, birth length 48 centimeters, Gravida Medical Delivery a) PRC No:_0181954________
3 Para 3 (3003) Center Valid Until: _03-27-2013______
b) PNA No.:_078140_________
Valid Until: __December 2010_
4 47-28-97 Pregnancy Uterine Full Term, double footling Lopez, Analiza 33 years old June 04, 2010 2:03 am Male Eastern Normal Mrs. Azucena T. Abit, RN, MAN
breech, delivered by partial breech extraction to a Visayas Spontaneous Date Signed: _
live baby boy APGAR score – 1 Total meconium Regional Vaginal Degree: BSN, RN, MAN______
stain – amniotic fluid, birth weight 3,300grams, Medical Delivery a) PRC No:_0181954________
birth length 52 centimeters, Gravida 1 Para 1 Center Valid Until: _03-27-2013______
(1001) b) PNA No.:_078140_________
Valid Until: __December 2010_

5 47-28-92 Pregnancy Uterine Full Term, cephalic delivered Ocasla, Marilyn 38 years old June 04, 2010 5:35 am Male Eastern Normal Mrs. Azucena T. Abit, RN, MAN
by spontaneous vaginal delivery to a live Baby Visayas Spontaneous Date Signed: _
boy APGAR Score-9, Meconium stain –amniotic Regional Vaginal Degree: BSN, RN, MAN______
Medical Delivery a) PRC No:_0181954________
fluid, birth weight 3,500 grams, birth length 49
Center Valid Until: _03-27-2013______
centimeters Gravida3 Para 3 (3002)
b) PNA No.:_078140_________
Valid Until: __December 2010_

NOTED BY CONCURRED BY: APPROVED BY:

MRS. IRENE JOY G. BERISO, RN, MAN
Signature over Printed Name of Clinical Coordinator
SSCHS, College of Nursing
Date signed: __________________________
Degree: BSN, RN, MAN______________
a)PRC No.: 0300704___________________
Valid Until: October 20, 2011____________
b)PNA No.: 078156____________________
Valid Until: December, 2010_____________
CONCURRED BY:
MRS. TERESITA V. BERENGUER, BSN, RN, MAN MRS. CAROLINA D. BARROT, RN, MAN
Signature over Printed Name of Chief Nurse
MRS. JOSEFINA M. MORILES, RN, MN Signature over Printed Name of Dean
Signature over Printed Name of Chief Nurse
Eastern Visayas Regional Medical Center SSCHS, College of Nursing
Ormoc District Hospital
Date signed:________________________________________ Date signed: _______________________
Date signed: _______________________
Degree: BSN, RN, MAN____________________________ Degree: BSN, RN, MAN___________
Degree: BSN, RN, MN____________
a)PRC No.: 0046504_________________________________ a)PRC No.: 0133674_________________
a)PRC No.: 0077714________________
Valid Until: October 14, 2010__________________________ Valid Until: September 21, 2011________
Valid Until: September 18, 2011_______
b)PNA No.: 3961____________________________________ b)PNA No.: 078155 _________________
b)PNA No.: 6005___________________
Valid Until: Life Member______________________________ Valid Until: December, 2010___________
Valid Until: Life Member_____________
c.) ADPCN No.: ______________________
Valid Until: __________________________

I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete statement pursuant to the
provisions of pertinent laws, rules and regulations of the Republic of the Philippines.

Subscribed and sworn before me this _____ day of ___________ 20______, Philippines.
_________________________________
Signature of Applicant

Doc. No. _________________

Page No. _________________
Book No. _________________
Series of: _________________