ODC Form 2A O.R.

SCRUB FORM Major

SURGICAL SCRUB in ________________________________________________________

Hospital , Municipality /City / Province

Prepared by: Printed Name with Signature of Student _______________________________________

Date Performed and Time Started

Patients INITIAL (only) Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: TITA B. BUENAOBRA, RN MAN Clinical Coordinator

PRC I.D. No. ___________0241227_________________ Valid Until ___01/ 03/ 2013___ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: MARY NELLIE T. ROA, DMD, RN MAN Dean

PRC I.D. No. ____________________________________ Valid Until _________________ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

STRICLTY NO DESIGNATES

ODC Form 2B O.R. Minor Form

SURGICAL SCRUB in ________________________________________________________

Hospital , Municipality /City / Province

Prepared by: Printed Name with Signature of Student _______________________________________

Date Performed and Time Started

Patients INITIAL (only) Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: TITA B. BUENAOBRA, RN MAN Clinical Coordinator

Approved by: MARY NELLIE T. ROA, DMD, RN MAN Dean

PRC I.D. No. ___________0241227_________________ Valid Until ___01/ 03/ 2013___ PRC I.D. No. ____________________________________ Valid Until _________________ Date document is signed: ______________________________ Time _________________ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree EarnedMASTER OF ARTS IN NURSING

STRICLTY NO DESIGNATES

ODC Form 1A Actual Delivery Form

ACTUAL DELIVERY in ________________________________________________________

Hospital/ Home/ Lying-In Clinic , Municipality /City / Province

Prepared by: Printed Name with Signature of Student _______________________________________

Date Performed and Time Started

Patients INITIAL (only) Case Number

(not applicable for Birthing/ Lying-In Clinic/ Homes)

D.R. Nurse On Duty PROCEDURE PERFORMED

(Name and Signature) (If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: TITA B. BUENAOBRA, RN MAN Clinical Coordinator

PRC I.D. No. ___________0241227_________________ Valid Until ___01/ 03/ 2013___ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: MARY NELLIE T. ROA, DMD, RN MAN Dean

PRC I.D. No. ____________________________________ Valid Until _________________ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned:MASTER OF ARTS IN NURSING

STRICLTY NO DESIGNATES

ODC Form 1B AssitedDelivery Form

ACTUAL DELIVERY in ________________________________________________________

Hospital/ Home/ Lying-In Clinic , Municipality /City / Province

Prepared by: Printed Name with Signature of Student _______________________________________

Date Performed and Time Started

Patients INITIAL (only) Case Number

(not applicable for Birthing/ Lying-In Clinic/ Homes)

D.R. Nurse On Duty PROCEDURE PERFORMED

(Name and Signature) (If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: TITA B. BUENAOBRA, RN MAN Clinical Coordinator

PRC I.D. No. ___________0241227_________________ Valid Until ___01/ 03/ 2013___ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: MARY NELLIE T. ROA, DMD, RN MAN Dean

PRC I.D. No. ____________________________________ Valid Until _________________ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

STRICLTY NO DESIGNATES

ODC Form 1C CORD CARE Form

IMMEDIATE NEWBORN CORD CARE in_______________________________________________________________________________

Hospital/ Home/ Lying-In Clinic , Municipality /City / Province

Prepared by: Printed Name with Signature of Student _______________________________________

Date Performed and Time Started

Patients INITIAL (only) Case Number

(not applicable for Birthing/ Lying-In Clinic/ Homes)

Immediate Newborn Cord Care PERFORMED

Indicate where performed e.g. D.R. Nursery, NICU, or Home

D.R. Nurse On Duty

(Name and Signature) (If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: TITA B. BUENAOBRA, RN MAN Clinical Coordinator

PRC I.D. No. ___________0241227_________________ Valid Until ___01/ 03/ 2013___ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: MARY NELLIE T. ROA, DMD, RN MAN Dean

PRC I.D. No. ____________________________________ Valid Until _________________ Date document is signed: ______________________________ Time _________________ Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

STRICLTY NO DESIGNATES