ODC Form 1C

CORD CARE FORM

Jose Rizal University

80 Shaw Blvd., Mandaluyong city

Tel: 531-8031 / Fax: 532-1418 / E-mail: jru@jru.edu

Website: www.jru.edu.ph

SURGICAL SCRUB in: _____________________________________________________________________________

Hospital, City / Municipality / Province

Prepared by: _____________________________________________________________________________

Printed name with signature of student

Date Performed and Patient’s Initials (only)
Time Started Case Number (Not Applicable for
Birthing/Lying- In Clinics/Homes)
Immediate Newborn Cord Care DR Nurse on Duty Supervised by
Performed
(Name and Signature) Clinical Instructor
(Indicate where performed, i.e. DR, Nursery,
NICU, or Home)
(If Midwife on Duty, Signature Not Required) (Name and Signature)
 Noted by: _______________________________________________________ Approved by: _______________________________________________________

Printed Name and Signature Printed Name and Signature

Clinical Instructor, PRC ID no.: ______________________ Valid until: ___________ Dean, PRC ID no.: ______________________ Valid until: ___________

Date document is signed: _________________________ Time: ___________ Date document is signed: _________________________ Time: ___________

Specify Highest Degree Earned: _______________________________________________ Specify Highest Degree Earned: _______________________________________________

(STRICTLY NO DESIGNATES)