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
and
Time Started
Patients INITIALS (only)
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse On Duty
(Name AND Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number












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
LOGO
ODC Form 2A
O.R. SCRUB FORM
Major


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
and
Time Started
Patients INITIALS Only
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number












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
LOGO
ODC Form 2B
O.R. MINOR 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
and
Time Started
Patients INITIAL Only
PROCEDURE
PERFORMED

D.R. Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not
Required)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number
(not applicable for Birthing/Lying-
In Clinics/Homes)








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
LOGO
ODC Form 1A
ACTUAL 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
and
Time Started
Patients INITIAL Only
PROCEDURE
PERFORMED


ASSISTED DELIVERY
D.R. Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not
Required)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number
(not applicable for Birthing/Lying-
In Clinics/Homes)








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
LOGO
ODC Form 1B
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)
IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ______________________________________________
Date Performed
and
Time Started
Patients INITIAL Only Immediate Newborn Cord Care
PERFORMED
Indicate where performed e.g. D.R., Nursery,
NICU, or Home
Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
signature not required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Case Number
(not applicable for Birthing
Homes/Lying-In Clinics/Homes)










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
LOGO
ODC Form 1C
CORD CARE FORM