ODC Form 2A

O.R. SCRUB FORM

SCHOOL Major

LOGO NAME OF SCHOOL

COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
SURGICAL SCRUB in ________________________________________________________________________
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student ______________________________________________

Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY

and SURGICAL PROCEDURE (Name AND Signature) Clinical Instructor
Time Started Case Number Name and Signature
PERFORMED

Noted by: _______________________________________________ Approved by: ___________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________
Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)
 ODC Form 2B
O.R. MINOR FORM
SCHOOL

LOGO NAME OF SCHOOL

COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
SURGICAL SCRUB in ________________________________________________________________________
Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ______________________________________________

Date Performed Patient’s INITIALS Only O.R. Nurse On Duty SUPERVISED BY

and SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
Time Started Case Number Name and Signature
PERFORMED

Noted by: _______________________________________________ Approved by: ___________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________
Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)
 ODC Form 1A
SCHOOL ACTUAL DELIVERY FORM

LOGO

NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
ACTUAL DELIVERY in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ______________________________________________

Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying-
In Clinics/Homes)
Signature Not
Required)

Noted by: _______________________________________________ Approved by: ___________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________
Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)
 SCHOOL
ODC Form 1B
LOGO ASSISTED DELIVERY
FORM
NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
ACTUAL DELIVERY in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ______________________________________________

Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying-
In Clinics/Homes)
Signature Not
ASSISTED DELIVERY Required)

Noted by: _______________________________________________ Approved by: ___________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________
Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)
 SCHOOL ODC Form 1C
CORD CARE FORM
LOGO

NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ______________________________________________

Date Performed Patient’s INITIAL Only Immediate Newborn Cord Care Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Case Number
Time Started Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty, Name and Signature
(not applicable for Birthing
Homes/Lying-In Clinics/Homes) NICU, or Home signature not required)

Noted by: _______________________________________________ Approved by: ___________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________
Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)