The document appears to be a record of clinical experiences for a nursing student. It includes sections listing major operations, minor procedures, deliveries handled and assisted with, and cord dressings. For each experience, it records patient details, date, type of procedure or surgery, hospitals and supervising clinicians. Signatures and credentials of supervisors and the dean are provided to validate the documented experiences.

1. NAME OF STUDENT: ______________________________________________________________________________________________________________
First Course (if any): _______________________________________________ ____ __________________
Name and Address of School: Holy Trinity University ______________________________________________________________________________________
School Graduated From: __________________________________________ _________________________
Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________
Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________
Year Graduated (BSN Program):____________________________________ _________________________
Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________
I. MAJOR OPERATIONS
Date of Case Type of Name of Name of Name of Signature of
No. Name of Patient Medical Diagnosis Type of Surgery
Operation No. Anesthesia Surgeon Hospital Qualified C.I. Qualified C.I.
1.
2.
3.
4.
5.
Supervised By:_________________________________________________________ ____________________
(Signature over printed name of Clinical Supervisor)
Date Signed:____________________________________________________________ ____________________
Degree:BSN, RN, MAN _______________________________________________________________________
PRC No: _______________________________ Valid Until: _______________ _________________________
PNA No: _______________________________ Valid Until: _______________ _________________________
Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________
Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________
(Signature over printed name of Chief Nurse) (Signature over printed name of Dean)
Date Signed: __________________________________________________________________________________
Date Signed: _______________________________________________________________________________
Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________
Degree: BSN, RN,
PRC No: _______________________________ Valid Until: ____________________________________________
PRC No: ______________________________ Valid Until_______________________ _____________________
PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________
PNA No: ______________________________Valid Until: ______________________ _____________________
ADPCN No: ___________________________ Valid Until: ___________________________________________

2. NAME OF STUDENT: ______________________________________________________________________________________________________________
First Course (if any): _______________________________________________ ____ __________________
Name and Address of School: Holy Trinity University ______________________________________________________________________________________
School Graduated From: __________________________________________ _________________________
Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________
Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________
Year Graduated (BSN Program):____________________________________ _________________________
Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________
II. MINOR SCRUBS
Date of Case Type of Name of Name of Name of Signature of
No. Name of Patient Medical Diagnosis Type of Surgery
Operation No. Anesthesia Surgeon Hospital Qualified C.I. Qualified C.I.
1.
2.
3.
4.
5.
Supervised By:_________________________________________________________ ____________________
(Signature over printed name of Clinical Supervisor)
Date Signed:____________________________________________________________ ____________________
Degree:BSN, RN, MAN _______________________________________________________________________
PRC No: _______________________________ Valid Until: _______________ _________________________
PNA No: _______________________________ Valid Until: _______________ _________________________
Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________
Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________
(Signature over printed name of Chief Nurse) (Signature over printed name of Dean)
Date Signed: __________________________________________________________________________________
Date Signed: _______________________________________________________________________________
Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________
Degree: BSN, RN,
PRC No: _______________________________ Valid Until: ____________________________________________
PRC No: ______________________________ Valid Until_______________________ _____________________
PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________
PNA No: ______________________________Valid Until: ______________________ _____________________
ADPCN No: ____________________________ Valid Until: __________________________________________

3. NAME OF STUDENT:. _____________________________________________________________________________________________________________
First Course (if any): _______________________________________________ ____ __________________
Name and Address of School: Holy Trinity University ______________________________________________________________________________________
School Graduated From: __________________________________________ _________________________
Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________
Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________
Year Graduated (BSN Program):____________________________________ _________________________
Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________
III. DELIVERIES HANDLED
Date of Time of Signature of
No. Case No. Name and Age of Patient Type of Delivery Gender of Baby Name of Hospital Name of Qualified C.I.
Delivery Delivery Qualified C.I.
1.
2.
3.
4.
5.
Supervised By:_________________________________________________________ __________________
(Signature over printed name of Clinical Supervisor)
Date Signed:____________________________________________________________ _________________
Degree:BSN, RN, MAN _____________________________________________________________________
PRC No: ______________________________ Valid Until: _______________ _______________________
PNA No: ______________________________ Valid Until: _______________ _______________________
Noted by: AGNES B. PALAO, RN, MAN, Ph.D. ___________________________________________
(Signature over printed name of Chief Nurse) Noted By: _ MARIA CELINA G. CASIS, RN, MSN ________________________________
Date Signed: __________________________________________________________________________________ (Signature over printed name of Dean)
Degree:BSN, RN, MPA, Ph.D. _____________________________________________________________________
Date Signed: _____________________________________________________________________________
PRC No: ______________________________ Valid Until: _____________________________________________ BSN, RN, MSN _____________________________________________________________________
Degree:
PNA No: 12564 _________________________ Valid Until: Lifetime Member___ ____________________________
PRC No: _____________________________ Valid Until_______________________ __________________
PNA No: ______________________________Valid Until: ______________________ ___________________
ADPCN No: Valid Until: ________________________________________

4. NAME OF STUDENT: ______________________________________________________________________________________________________________
First Course (if any): _______________________________________________ ____ __________________
Name and Address of School: Holy Trinity University ______________________________________________________________________________________
School Graduated From: __________________________________________ _________________________
Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________
Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________
Year Graduated (BSN Program):____________________________________ _________________________
Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________
IV. DELIVERIES ASSISTED
Date of Time of Gender of Signature of
No. Case No. Name and Age of Patient Type of Delivery Name of Hospital Name of Qualified C.I.
Delivery Delivery Baby Qualified C.I.
1.
2.
3.
4.
5.
Supervised By:_________________________________________________________ ____________________
(Signature over printed name of Clinical Supervisor)
Date Signed:____________________________________________________________ ____________________
Degree:BSN, RN, MAN _______________________________________________________________________
PRC No: _______________________________ Valid Until: _______________ _________________________
PNA No: _______________________________ Valid Until: _______________ _________________________
Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________
Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________
(Signature over printed name of Chief Nurse) (Signature over printed name of Dean)
Date Signed: __________________________________________________________________________________
Date Signed: _______________________________________________________________________________
Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________
Degree: BSN, RN,
PRC No: _______________________________ Valid Until: ____________________________________________
PRC No: ______________________________ Valid Until_______________________ _____________________
PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________
PNA No: ______________________________Valid Until: ______________________ _____________________
ADPCN No: Valid Until: ___________________________________________

5. NAME OF STUDENT: ______________________________________________________________________________________________________________
First Course (if any): _______________________________________________ ____ __________________
Name and Address of School: Holy Trinity University ______________________________________________________________________________________
School Graduated From: __________________________________________ _________________________
Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________
Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________
Year Graduated (BSN Program):____________________________________
Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________
V. CORD DRESSING
Gender of Signature of
No. Case No. Date of Delivery Name of Baby Name and Age of Mother Name of Hospital Name of Qualified C.I.
Baby Qualified C.I.
1.
2.
3.
4.
5.
Supervised By:_________________________________________________________ ____________________
(Signature over printed name of Clinical Supervisor)
Date Signed:____________________________________________________________ ____________________
Degree:BSN, RN, MAN _______________________________________________________________________
PRC No: _______________________________ Valid Until: _______________ _________________________
PNA No: _______________________________ Valid Until: _______________ _________________________
Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________
Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________
(Signature over printed name of Chief Nurse) (Signature over printed name of Dean)
Date Signed: __________________________________________________________________________________
Date Signed: _______________________________________________________________________________
Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________
Degree: BSN, RN,
PRC No: _______________________________ Valid Until: ____________________________________________
PRC No: ______________________________ Valid Until_______________________ _____________________
PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________
PNA No: ______________________________Valid Until: ______________________ _____________________
ADPCN No: Valid Until: ___________________________________________