Notre Dame University College of Health Sciences Cotabato City

Name of Student: Name and Address of School:

Notre Dame University, College of Health Sciences Notre Dame Avenue, Cotabato City Accreditation Level: Level 1 Date School/Program was recognized: November 30, 1984 First Course (If Any): Not Applicable Year of Admission in the Bachelor in Nursing Program: 2007

Year Granted: Recognition Number: School Graduated from: Year Graduated (BSN Program):

1984 170 s. 1984 Not Applicable 2011

Year: 1984 Year: Not Applicable School Code: 0872

I ASSIST No Case No. Diagnosis Name of Patient Age Date of Delivery Time of Delivery Gender of Baby Name of Institution Type of Delivery Supervised by: Name and Signature of Qualified Clinical Instructor

Prepared by: (your name here)

Signature over printed name

Noted by:

Concurred by:

Approved by:

LORENITA T. CELESTE, R.N., M.A.N. Signature over printed name of Clinical Coordinator Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing a. PRC License No.: 0115171 Valid until: April 27, 2012 b. PNA No.: Valid until:

Signature over printed name of Chief Nurse (Institutions name here) Date Signed: Degree: Bachelor of Science in Nursing a. PRC License No.: Valid until: b. PNA No.: Valid until: c. ANSAP License No.: Valid until:

(Chief Nurses name here)

NANCY USMAN GUINTA, R.N., M.A.N Signature over Printed name of the Dean College of Health Sciences, Notre Dame University Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing a. PRC License No.: 0228856 Valid until: September 14, 2013 b. PNA No.: Valid until: c. ADPCN License No.: Valid until:

Notre Dame University College of Health Sciences Cotabato City

Name of Student: Name and Address of School:

Notre Dame University, College of Health Sciences Notre Dame Avenue, Cotabato City Accreditation Level: Level 1 Date School/Program was recognized: November 30, 1984 First Course (If Any): Not Applicable Year of Admission in the Bachelor in Nursing Program: 2007

Year Granted: Recognition Number: School Graduated from: Year Graduated (BSN Program):

1984 170 s. 1984 Not Applicable 2011

Year: 1984 Year: Not Applicable School Code: 0872

I CORD DRESS No Case No. Date Performed Name of Baby Name of Mother Age Name of Institution Supervised by: Name and Signature of Qualified Clinical Instructor

Prepared by: (your name here)

Signature over printed name

Noted by:

Concurred by:

Approved by:

LORENITA T. CELESTE, R.N., M.A.N. Signature over printed name of Clinical Coordinator Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing c. PRC License No.: 0115171 Valid until: April 27, 2012 d. PNA No.: Valid until:

Signature over printed name of Chief Nurse (Institutions name here) Date Signed: Degree: Bachelor of Science in Nursing a. PRC License No.: Valid until: b. PNA No.: Valid until: c. ANSAP License No.: Valid until:

(Chief Nurses name here)

NANCY USMAN GUINTA, R.N., M.A.N Signature over Printed name of the Dean College of Health Sciences, Notre Dame University Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing d. PRC License No.: 0228856 Valid until: September 14, 2013 e. PNA No.: Valid until: f. ADPCN License No.: Valid until:

Notre Dame University College of Health Sciences Cotabato City

Name of Student: Name and Address of School:

Notre Dame University, College of Health Sciences Notre Dame Avenue, Cotabato City Accreditation Level: Level 1 Date School/Program was recognized: November 30, 1984 First Course (If Any): Not Applicable Year of Admission in the Bachelor in Nursing Program: 2007

Year Granted: Recognition Number: School Graduated from: Year Graduated (BSN Program):

1984 170 s. 1984 Not Applicable 2011

Year: 1984 Year: Not Applicable School Code: 0872

I HANDLE No Case No. Diagnosis Name of Patient Age Date of Delivery Time of Delivery Gender of Baby Name of Institution Type of Delivery Supervised by: Name and Signature of Qualified Clinical Instructor

Prepared by: (your name here)

Signature over printed name

Noted by:

Concurred by:

Approved by:

LORENITA T. CELESTE, R.N., M.A.N. Signature over printed name of Clinical Coordinator Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing e. PRC License No.: 0115171 Valid until: April 27, 2012 f. PNA No.: Valid until:

Signature over printed name of Chief Nurse (Institutions name here) Date Signed: Degree: Bachelor of Science in Nursing d. PRC License No.: Valid until: e. PNA No.: Valid until: f. ANSAP License No.: Valid until:

(Chief Nurses name here)

NANCY USMAN GUINTA, R.N., M.A.N Signature over Printed name of the Dean College of Health Sciences, Notre Dame University Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing g. PRC License No.: 0228856 Valid until: September 14, 2013 h. PNA No.: Valid until: i. ADPCN License No.: Valid until:

Notre Dame University College of Health Sciences Cotabato City

Name of Student: Name and Address of School:

Notre Dame University, College of Health Sciences Notre Dame Avenue, Cotabato City Accreditation Level: Level 1 Date School/Program was recognized: November 30, 1984 First Course (If Any): Not Applicable Year of Admission in the Bachelor in Nursing Program: 2007

Year Granted: Recognition Number: School Graduated from: Year Graduated (BSN Program):

1984 170 s. 1984 Not Applicable 2011

Year: 1984 Year: Not Applicable School Code: 0872

I MAJOR OPERATION No Date of Operation Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name of OR Scrub Nurse Signature of OR Scrub Nurse Supervised by: Name and Signature of Qualified Clinical Instructor

Prepared by: (your name here)

Signature over printed name

Noted by:

Concurred by:

Approved by:

LORENITA T. CELESTE, R.N., M.A.N. Signature over printed name of Clinical Coordinator Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing g. PRC License No.: 0115171 Valid until: April 27, 2012 h. PNA No.: Valid until:

Signature over printed name of Chief Nurse (Institutions name here) Date Signed: Degree: Bachelor of Science in Nursing g. PRC License No.: Valid until: h. PNA No.: Valid until: i. ANSAP License No.: Valid until:

(Chief Nurses name here)

NANCY USMAN GUINTA, R.N., M.A.N Signature over Printed name of the Dean College of Health Sciences, Notre Dame University Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing j. PRC License No.: 0228856 Valid until: September 14, 2013 k. PNA No.: Valid until: l. ADPCN License No.: Valid until:

Notre Dame University College of Health Sciences Cotabato City

Name of Student: Name and Address of School:

Notre Dame University, College of Health Sciences Notre Dame Avenue, Cotabato City Accreditation Level: Level 1 Date School/Program was recognized: November 30, 1984 First Course (If Any): Not Applicable Year of Admission in the Bachelor in Nursing Program: 2007

Year Granted: Recognition Number: School Graduated from: Year Graduated (BSN Program):

1984 170 s. 1984 Not Applicable 2011

Year: 1984 Year: Not Applicable School Code: 0872

I MINOR OPERATION No Date of Operation Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name of OR Scrub Nurse Signature of OR Scrub Nurse Supervised by: Name and Signature of Qualified Clinical Instructor

Prepared by: (your name here)

Signature over printed name

Noted by:

Concurred by:

Approved by:

LORENITA T. CELESTE, R.N., M.A.N. Signature over printed name of Clinical Coordinator Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing i. PRC License No.: 0115171 Valid until: April 27, 2012 j. PNA No.: Valid until:

Signature over printed name of Chief Nurse (Institutions name here) Date Signed: Degree: Bachelor of Science in Nursing j. PRC License No.: Valid until: k. PNA No.: Valid until: l. ANSAP License No.: Valid until:

(Chief Nurses name here)

NANCY USMAN GUINTA, R.N., M.A.N Signature over Printed name of the Dean College of Health Sciences, Notre Dame University Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing m. PRC License No.: 0228856 Valid until: September 14, 2013 n. PNA No.: Valid until: o. ADPCN License No.: Valid until:

Note: PLEASE READ THE INSTRUCTIONS CAREFULLY. a. The diagnoses and/or procedures must be written in full, not abbreviated ; STRICTLY NO ABBREVIATIONS; b. Please ensure accuracy of entries, i.e. spelling of names, diagnoses, procedures; license numbers; dates; case numbers. c. The entry of cases follows from first to the most recent case earned; d. The middle initial of the patient is OPTIONAL; e. The patients name may be written in any of the following manner: i. Surname (Family Name), First Name (Given Name) and Middle Initial ex. Dela Cruz, Angela D. ii. First Name (Given Name), Middle Initial and Surname (Family Name) ex. Angela D. Dela Cruz iii. Surname (Family Name), First Name (Given Name) ex. Dela Cruz, Angela iv. First Name (Given Name) and Surname (Family Name) ex. Angela Dela Cruz f. It is encouraged that CONSISTENCY in the format of the entry of names is observed; g. Cases earned in medical missions should be specifically identified; ex.I MINOR OPERATION No Date of Operation Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name of OR Scrub Nurse Signature of OR Scrub Nurse Supervised by: Name and Signature of Qualified Clinical Instructor

3

0208871

N.B. Case no. 3 was earned at a medical mission.

h. For signatories with expired or about to expire (i.e. before May 2011) PRC license numbers, PNA numbers, ADPCN license numbers, or ANSAP license numbers, please leave the space provided for each BLANK; i. Sign your exhibit forms before submitting them;

j. The No. column should contain the corresponding number of the case earned; ex.I CORD DRESS No Case No. Date Performed Name of Baby Name of Mother Age Name of Institution Supervised by: Name and Signature of Qualified Clinical Instructor

1

July 28, 2009

4

February 19, 2010

k. The PRC Exhibit Forms are done in each individual affiliating institution where the cases were earned. It should bear the names of the Clinical Coordinator, Chief Nurse, and the College Dean respectively, at the bottom part. However, cases earned at the health centers, lying in clinics, home deliveries and medical missions DO NOT require the name of the Chief Nurse; ex.Noted by: LORENITA T. CELESTE, R.N., M.A.N. Signature over printed name of Clinical Coordinator Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing k. PRC License No.: 0115171 Valid until: April 27, 2012 l. PNA No.: Valid until: Approved by:

NANCY USMAN GUINTA, R.N., M.A.N Signature over Printed name of the Dean College of Health Sciences, Notre Dame University Date Signed: Degree: Bachelor of Science in Nursing Master of Arts in Nursing p. PRC License No.: 0228856 Valid until: September 14, 2013 q. PNA No.: Valid until: r. ADPCN License No.: Valid until:

l. Please take note that all entries in the slips must conform to those written in the PRC Exhibit Forms; otherwise, it might cause delay in the students processing because of several questions asked to validate the authenticity of the case earned, if not its disqualification. m. Both DR and cord care cases must be earned with an interval of 30 minutes in between each case. n. Two similar cases may be allowed in both major and minor operations. o. Only one copy is required for every PRC Exhibit Form and can be reproduced after properly signed by all signatories. p. Lastly, READ and VERIFY before speculating and spreading word. THANK YOU.

LIST OF CHIEF NURSESName of Chief Nurse PRC Registration Number Validity PNA Number Validity Name of Institution and Location

1. Rouena C. Alpas, RN 2. Nolah C. Biscarra, RN 3. Irene Joy N. Burgos, RN 4. Leonor V. Clemea, RN, MN 5. Trinidad S. Dignadice, RN 6. Maria Cristina M. Filomeno, RN 7. Margie R. Garcia, RN 8. Sheila B. Garcia, RN 9. Zenaida J. Idillo, RN 10. Nursia M. Ismael, RN 11. Mamerta N. Laforteza, RN, MAN 12. Vilma P. Ligo, RN, MN 13. Bernadette A. Patrona, RN, RM, MAN 14. Amy Grace C. Poblador, RN 15. Norma P. Reyes, RN 16. LTC MYRNA P SARVIDA NC 17. Julie Fe D. Sumagit, RN 18. Sr. Shirley R. Tangga, OP, RN 19. Nelson B. Villarubia, RN

0144360 0428590 0428625 0080558 0092867 0204540 0543867 0485231 0068167 0147178 0061842 0078598 0058269 0186879 33033 0082538 0124735 0366483 0430613

03/19/2012 06/18/1012 12/02/2010 12/14/2012 05/31/2012 07/29/2012 06/08/2012 01/22/2011 09/25/2010 06/12/2011 10/17/2012 07/27/2012 03/15/2011 11/12/2010 04/17/2011 02/16/2013 07/04/2011 09/21/2011 04/20/2013

18003

Lifetime

Aleosan District Hospital Aleosan

Midsayap Community Doctors Hospital Midsayap Kabacan

Kabacan Polymedic Cooperative Hospital Cotabato Medical Specialist Hospital Cotabato City Shariff Aguak

10217

Lifetime

Maguindanao Provincial Hospital Quijano Clinic and Hospital, Inc. Tacurong City Esperanza Midsayap

Our Lady of Hope Medical Clinic and Hospital Dr. Roland P. Dela Cruz Memorial Hospital Cotabato Sanitarium Maternity and Childrens Hospital Sultan Kudarat Dalican

Dinaig Municipal Hospital Sultan Kudarat Doctors Hospital Tacurong City

12792 9575

Lifetime Lifetime

South Cotabato Provincial Hospital Koronadal City Isulan

Sultan Kudarat Provincial Hospital President Roxas Provincial Community Hospital New Cebu

8225

Lifetime Lifetime

Cotabato Regional and Medical Center Cotabato City

Camp Siongco Station Hospital Datu Odin Sinsuat Midsayap

Dr. Amado B. Diaz Provincial Foundation Hospital Notre Dame Hospital and School of Midwifery Cotabato City

Cruzado Medical Clinic Hospital and Pharmacy

Pikit

Notre Dame University College of Health Sciences Cotabato City List of Clinical Instructors PRC Registration Number 0349435 0300898 0213172 0337475 0377172 0494929 0394163 0381703 0223197 0301413 0411469 0302591 0214532 0313312 0431295 0185675 0284966 0458125 0301615 0401791 0463885 0334842 0285600 0428693 0463836 0476337 0382445 0218823 0254940 0227842 0227818 0458364 0327069 0284921 0428743 0586886 0584644 0106927 0313281 0330644 0238852 0180665 0584712 0114094 PRC Registration Number 45. Notario, Renalyn C. 46. Olivo, Vincent Ryan F. 47. Ong, Joybelle G. 48. Ortuoste, Sean Anthony E. 49. Pegarro, Kathleya Grace N. 50. Pelaez, Ma. Liza B. 51. Penda, Bai Jasmin C. 52. Rayray, Imee D. 53. Resquites, Honeylet C. 54. Salgado, Hanna Teresa C. 55. Salgado, Norma C. 56. Sambolawan, Adjuri E. 57. Sarahina, Christy Joy P. 58. Sibal, Shenneth Kenneth A. 59. Siong, Evelyn C. 60. Sumail, Meriam G. 61. Sumayo, Simer Jane L. 62. Tamse, Katherine Marie C. 63. Tandog, Ian C. 64. Tillo, Jay C. 65. Tolentino, Joanne T. 66. Tolentino, Regina R. 67. Unson, Arjohn W. 68. Unte, Amor Fe A. 69. Usman, Noor-Alam M. 70. Uson, Judelyn T. 71. Uy, Reneth U. 72. Viloria, Chiqui Lovella Joy K. 73. Wong, Sheryl Lyn W. 74. Celeste, Lorenita T. valid until 75. Guinta, Nancy U. valid until 0356833 0395594 0413726 0382424 0364079 0091259 0413682 0391272 0432320 0586986 0149710 0413438 0364201 0393369 0157577 0161774 0462085 0490180 0413569 0413530 0432606 0111572 0382606 0382418 0335096 0349055 0367441 0413455 0431122

Name of CI 1. Abella, Lyreyann C. 2. Abutazil, Mary Ann A. 3. Agarrado, Maribelle S. 4. Aguilar, Jonathan P. 5. Agulo, Agripino Jr. N. 6. Algabre, May Emerald G. 7. Alonzo, Aimee Grace R. 8. Alonzo, Almira B. 9. Ampatuan, Bai Wilmina S. 10. Austria, Mary Grace P. 11. Bajao, Nio Crisol T. 12. Balawag, Mary Jane K. 13. Bisnar, Joyce C. 14. Bose, Gideon E. 15. Bueno, Jeremiah P. 16. Calib, Mariam B. 17. Cases, Maureen Laurice T. 18. Castro, Aileen S. 19. Cayena, Hazel D. 20. Chio, Joana Krisitine A. 21. Dayrit, Gina C. 22. Delos Reyes, Edison J 23. Dimacisil, Zaida M. 24. Enok, Jehan B. 25. Esmundo, Cris Angelo G. 26. Estaniel, Aldila Cannon C. 27. Facultad, Joy Chie T. 28. Fiesta, Mabuhay Apollo B. 29. Gallego, Nimfa F. 30. Gimenez, Toni Rose G. 31. Hermoso, Girlie J G. 32. Hinaut, Rhenee E. 33. Ibrahim, Lelibeth W. 34. Jakosalem, Agnes D. 35. Javier, Imelda V. 36. Lalang, Mardeja U. 37. Lao, Sychelle V. 38. Lim, Antonio Jr. V. 39. Lorenzo, Anthony Francis Eugene A. 40. Macala, Allan U. 41. Malacad, Remy Rose P. 42. Mama, Alona T. 43. Mana-ay, Alejandro II P. 44. Margallo, Virginia S. Name of CI

0115171 04/27/2012 0228856 09/14/2013

SIGNATORIES FOR RESIGNED CLINICAL INSTRUCTORS School Year 2010 2011

Vincent Ryan F. Olivo, RN

Sultan Kudarat Provincial HospitalImelda V. Javier, RN, RM PRC License No. 0428743 Imee D. Rayray, RN PRC License No. 0391272 Honeylet R. Mangulamas, RN, PTRP PRC License No. 0432320 Camp Siongco Station Hospital Chiqui Lovella Joy V. Clar, RN PRC License No. 0413455 Jeremiah P. Bueno, RN PRC License No. 0431295 Judelyn T. Uson, RN PRC License No. 0349055

President Roxas Provincial Community HospitalGideon E. Bose, RN PRC License No. 0313312 Pikit Rural Health Unit Ian C. Tandog, RN PRC License No. 0413569 Bai Jasmin C. Penda, RN

Dr. Amado B. Diaz Provincial Foundation HospitalImee D. Rayray, RN PRC License No. 0391272 Pikit Rural Health Unit Ian C. Tandog, RN PRC License No. 0413569

SIGNATORIES FOR HOSPITAL AND RHU COMPLETION OF CASES School Year 2010 2011 1. Notre Dame Hospital and School of Midwifery Amor Fe A. Unte, RN PRC License No. 0382418 Anthony Francis Eugene A. Lorenzo, RN PRC License No. 0313281 Regina R. Tolentino, RN, MAEd, EdD PRC License No. 0111572 Renalyn C. Notario, RN PRC License No. 0356833 Noraisa S. Nor, RN PRC License No. 0259068 Lyreyann C. Abella, RN PRC License No. 0349435 Alejandro P. Mana-ay II, RN PRC License No. 0584712 Arjohn W. Unson, RN PRC License No. 0382606 Ian C. Tandog, RN PRC License No. 0413569 Sean Anthony E. Ortuoste, RN PRC License No. 0382424 Almira B. Alonzo, RN PRC License No. 0381703 Evelyn C. Siong, RN PRC License No. 0157577 Aileen S. Castro, RN PRC License No. 0458125 Girlie J G. Hermoso, RN PRC License No. 0227818 Hazel D. Cayena, RN PRC License No. 0301615 Zaida M. Dimacisil, RN PRC License No. 0285600

2. Cotabato Medical Specialist Hospital

3. Cotabato Puericulture Center and General Foundation Hospital, Inc.

4. Parang; Simuay; Pinaring; Matanog; Katuli; Gang

5. Pikit

6. Aleosan

7. Cotabato City

8. Cotabato Sanitarium Maternity and Childrens Hospital; Macaguiling

9. Isulan, Sultan Kudarat

Imelda V. Javier, RN, RM PRC License No. 0428743 Imee D. Rayray, RN PRC License No. 0391272 Honeylet R. Mangulamas, RN, PTRP PRC License No. 0432320

10. Camp Siongco Station Hospital

Chiqui Lovella Joy V. Clar, RN PRC License No. 0413455 Jeremiah P. Bueno, RN PRC License No. 0431295 Judelyn T. Uson, RN PRC License No. 0349055

11. Broce; Tapian; Taviran; Dalican

Meriam G. Sumail, RN PRC License No. 0161774 Mariam B. Calib, RN PRC License No. 0185675

12. Mamasapano; Maganoy; Talayan; Datu Piang

Alona T. Mama, RN PRC License No. 0180665 Mary Jane K. Balawag, RN PRC License No. 0302591

13. Upi

Gina C. Dayrit, RN, MAEd PRC License No. 0463885 Mabuhay Apollo B. Fiesta, RN PRC License No. 0218823

14. Pigcawayan; Midsayap

Aimee Grace R. Alonzo, RN PRC License No. 0394163 Sheryl Lyn W. Wong, RN PRC License No. 0431122

15. Kabacan

Joy Chie T. Facultad, RN PRC License No. 0382445 Shenneth Kenneth A. Sibal, RN PRC License No. 0393369

16. Tacurong City; Koronadal City

Joanne T. Tolentino, RN PRC License No. 0432606 Adjuri E. Sambolawan, RN PRC License No. 0413438

17. General Santos City; Tupi; Polomolok

Agripino N. Agulo, Jr., RN PRC License No. 0377172 Reneth U. Uy, RN PRC License No. 0367441

PROGRAM OF STUDY

NAME: DESIGNATION: INSTITUTION: DEGREE: POST-GRADUATE STUDY:

Master of Arts in Nursing (MAN) Master of Nursing (MN) Other Allied Medical and Health Sciences (specify)

Semester of Masters Program

Units Earned/To be Earned

Remarks

CONFORME:

PROGRESS REPORT SCHOOL: Notre Dame University CITY: Cotabato City

Name of Chief Nurse

Post Graduate Study

Total Number of Units Earned

Number of Units to be Earned 2011 2012

PNA Number

Validity

PRC Registration Number

Validity

Signature