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NAME OF SCHOOL
COMPLETE BUSINESS ADDRESSPHONE 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/ProvincePrepared by:Printed Name with Signature of Student ______________________________________________Date PerformedandTime Started
Patient’s
INITIALS (only)
SURGICAL PROCEDUREPERFORMED
O.R. Nurse On Duty(Name AND Signature)
SUPERVISED BYClinical InstructorName and SignatureCase NumberPrepared by:Printed Name and Signature of Student ______________________________________________Date PerformedandTime Started
Patient’s
INITIALS Only
SURGICAL PROCEDUREPERFORMED
O.R. Nurse On Duty(Name and Signature)
SUPERVISED BYClinical InstructorName and SignatureCase Number
(STRICTLY NO DESIGNATES)[These Forms must be printed at the back of the 1
st
page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]O,R, Form 1B
O.R. CICRUCLATINGFORM
O.R. Form 1A
O.R. SCRUB FORMMajor
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