ODC Form 2A

BENGUET STATE UNIVERSITY College of Nursing
La Trinidad, Benguet, 2601 Philippines Phone number: 309-3882; Fax number: 422-2281; E-mail:ents3@yahoo.com; Web site:www.bsu.edu.ph LEVEL III RE-ACCREDITED,AACCUP,December 1,2007- November 3, 2011
SURGICAL SCRUB in BENGUET GENERAL HOSPITAL Name of Student: Date Performed and Time Started Patient Name Case Number Signature of student:

O.R. SCRUB FORM Major

PROCEDURE PERFORMED

O.R. Nurse On Duty

SUPERVISED BY:

Noted by: LAWRENCE C. CARANTO,RN Valid Until : September 11,2011 Clinical Coordinator, PRC I.D No.: 0311507 PNA No.: 063312 Valid Until: December 31,2010 Date signed: Time signed : Highest Nursing Degree Earned: Master of Arts in Nursing ( MAN)

Concurred by: VIRGINIA B. SAGUIDIC, RN Chief Nurse, PRC I.D No.: 003986 Valid until: January 15,2012 Valid until: Lifetime PNA No.: 02806 ANSAP No.: 01376 Valid until: December 31,2010 Time Signed: Date signed: Highest Nursing degree earned: Master of arts in Nursing (MAN)

Approved by: VICENTE G.PANAGAN JR.,RN Dean, PRC I.D. No. 296633 PNA No.: 063313 ADPCN NO.: 0838 Date signed: Specify Highest Nursing Degree Earned: Valid Until: April 11,2011 Valid Until:December 31,2010 Valid Until: December 31,2010 Time signed:

ODC orm A
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O.R. SCRUB FORM Major
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ted by: RENCE C. CARANTO,RN Clini al Coordinator, PRC li il PNA No.: li il: i : i i : i Nursi ree rned: ster of Arts in Nursing AN)
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Concurred by: ELENA . TAMPICAN,RN Chief Nurse, PRC .D No.: lid until: nuary , PNA No.: alid until: ifeti e alid until: December , ANSAP No.: Date signed: ime Signed: ighest Nursing degree earned: aster of arts in Nursing AN)
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Approved by: VICENTE .PANAGAN R.,RN
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Dean, PRC .D. No.
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