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PRC Form Com 14

PRC Form Com 14

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Published by: Marco Bernabe Jumaquio on Jun 17, 2011
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06/17/2011

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Bulacan State UniversityCOLLEGE OF NURSING
Guinhawa,City of Malolos, Bulacan(044) 791-94-00 bulsu@yahoo.com SURGICAL SCRUB in _____________________________________________________________ 
O.R. FORM 1A
Hospital, Municipality/ City/ Province
MAJOR O.R. SCRUB FORM
Date Performed andTime StartedPatients INITIALS (only)SURGICAL PROCEDUREPERFORMEDO.R. Nurse On Duty( Name and Signature)Supervised byClinical Instructor (Name and Signature)CASE NUMBER 
   S   t  u   d  e  n
 
   t
Signature over Printed NameCTC Number:_____________ Date :____________________ Place:____________________ 
C   h   i  e   f   N  u  r  s  e
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:___________ Valid Until:________ PNA No:___________Valid Until:_______ANSAP No:________ Valid Until:________ 
   C   l   i  n   i  c  a   l   C  o  o  r   d   i  n  a   t  o  r
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:_______
   D  e  a  n
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:____ Valid Until:________ PNA No:____ Valid Until:_______ADPCN No:__ Valid Until:________ 
NAME OF STUDENT: First Course:
NA
Name of School:
Bulacan State University
School Graduated:
NA
Address of School:
Guinhawa, City of Malolos, Bulacan
Year of Admission in the BSN Program:Recognition and Accreditation Level:Year Graduated from the BSN Program:Date When School was Recognized:
December 4, 2003 Board Resolution
 
 
Bulacan State UniversityCOLLEGE OF NURSING
Guinhawa,City of Malolos, Bulacan(044) 791-94-00 bulsu@yahoo.com SURGICAL SCRUB in _____________________________________________________________ 
O.R. FORM 1B
Hospital, Municipality/ City/ Province
MAJOR O.R. CIRCULATING FORM
Date Performed andTime StartedPatients INITIALS (only)SURGICAL PROCEDUREPERFORMEDO.R. Nurse On Duty( Name and Signature)Supervised byClinical Instructor (Name and Signature)CASE NUMBER 
   S   t  u   d  e  n
 
   t
Signature over Printed NameCTC Number:_____________ Date :____________________ Place:____________________ 
C   h   i  e   f   N  u  r  s  e
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:___________ Valid Until:_______PNA No:___________Valid Until:________ ANSAP No:________ Valid Until:________ 
   C   l   i  n   i  c  a   l   C  o  o  r   d   i  n  a   t  o  r
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:______ Valid Until:_______PNA No:______ Valid Until:_______
   D  e  a  n
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:____ Valid Until:_______PNA No:____ Valid Until:_______ADPCN No:__ Valid Until:_______
NAME OF STUDENT: First Course:
NA
Name of School:
Bulacan State University
School Graduated:
NA
Address of School:
Guinhawa, City of Malolos, Bulacan
Year of Admission in the BSN Program:Recognition and Accreditation Level:Year Graduated from the BSN Program:Date When School was Recognized:
December 4, 2003 Board Resolution
 
 
Bulacan State UniversityCOLLEGE OF NURSING
Guinhawa,City of Malolos, Bulacan(044) 791-94-00 bulsu@yahoo.com SURGICAL SCRUB in _____________________________________________________________ 
O.R. FORM 1C
Hospital, Municipality/ City/ Province
MINOR FORM
Date Performed andTime StartedPatients INITIALS (only)SURGICAL PROCEDUREPERFORMEDO.R. Nurse On Duty( Name and Signature)Supervised byClinical Instructor (Name and Signature)CASE NUMBER 
 
   S   t  u   d  e  n   t
Signature over Printed NameCTC Number:_____________ Date :____________________ Place:____________________ 
C   h   i  e   f   N  u  r  s  e
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:___________ Valid Until:_______PNA No:___________Valid Until:________ ANSAP No:________ Valid Until:________ 
   C   l   i  n   i  c  a   l   C  o  o  r   d   i  n  a   t  o  r
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:_______
   D  e  a  n
Signature over Printed NameDegree:_________________ Date Signed:_____________ PRC No:____ Valid Until:________ PNA No:____ Valid Until:________ ADPCN No:__ Valid Until:________ 
NAME OF STUDENT: First Course:
NA
Name of School:
Bulacan State University
School Graduated:
NA
Address of School:
Guinhawa, City of Malolos, Bulacan
Year of Admission in the BSN Program:Recognition and Accreditation Level:Year Graduated from the BSN Program:Date When School was Recognized:
December 4, 2003 Board Resolution
 

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