ODC Form 2A O.R. SCRUB FORM MAJOR UNIVERSITY OF SAN AGUSTIN GENERAL LUNA STREET, ILOILO CITY Tel.No.

: (033)337-48-41 to 44 Local 259, Fax No.: (033) 337-44-03, E-mail Address: cn@usa.edu.ph, Web-Site: SURGICAL SCRUB in Western Visayas Medical Center, Iloilo City Hospital/Municipality/City/Province Prepared by: Printed Name and Signature of Student: PATRICK Date Performed and Time Started Approved by: SOFIA COSETTE P. MONTEBLANCO, R.N. (Print Name and Signature) ALLEN SILLA ARANDA Dean, PRC I.D. No. 0042682 Valid Until February 1, 2010 Date document is signed: ______________ Time _______________ Patient¶s INITIAL Only specify Highest Nursing Degree Earned: ________________ O.R Nurse on Duty SUPERVISED BY Please SURGICAL PROCEDURE ____________________ (Name and Signature) Clinical Instructor Case Number Name and Signature PERFORMED Noted:________________________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D. No. ________________Valid Until _________ Date document is signed: _______________________Time _____________ Please specify Highest Nursing Degree Earned: _______________________

ODC Form 2B O.R. SCRUB FORM MINOR UNIVERSITY OF SAN AGUSTIN GENERAL LUNA STREET, ILOILO CITY Tel.No.: (033)337-48-41 to 44 Local 259, Fax No.: (033) 337-44-03, E-mail Address: cn@usa.edu.ph, Web-Site: SURGICAL SCRUB in Western Visayas Medical Center, Iloilo City Hospital/Municipality/City/Province

Prepared by: Printed Name and Signature of Student: PATRICK ALLEN SILLA ARANDA

Noted:________________________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D. No. ________________Valid Until _________ Date document is signed: _______________________Time _____________ Please specify Highest Nursing Degree Earned: _______________________

Approved by: SOFIA COSETTE P. MONTEBLANCO, R.N. (Print Name and Signature) Dean, PRC I.D. No. 0042682 Valid Until February 1, 2010 Date document is signed: ______________ Time _______________ Please specify Highest Nursing Degree Earned: ________________

Date Performed and Time Started

Patient¶s INITIAL Only ____________________ Case Number

SURGICAL PROCEDURE PERFORMED

O.R Nurse on Duty (Name and Signature)

SUPERVISED BY Clinical Instructor (Name and Signature)

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