ODC Form 2B

O.R. SCRUB FORM

Minor

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) and Surgical Procedure Performed OR Nurse on Duty Supervised by

Time Started Case Number (Name and Signature) Clinical Instructor

(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)