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PRC Forms New Format

PRC Forms New Format

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Published by: tsukuyomi526 on Sep 07, 2011
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NAME OF SCHOOL

COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Aress, !eb-Si"e
#I$ ACCREDITED% B& !HOM AND !HAT LE'EL, I()lusi*e Da"e +$ A))rei"a"i+(,
SUR-ICAL SCRUB i( ........................................................................
H+s/i"al, Mu(i)i/ali"0/Ci"0/Pr+*i()e
Pre/are b0%
Name +$ S"ue(" .............................................. Si1(a"ure +$ S"ue(" ...................................
Da"e
Per$+rme
a(
Time S"ar"e
Pa"ie("2s Name
PROCEDURE
PERFORMED
O3R3 Nurse O(
Du"0
#Name +(l0,
SUPER'ISED B&
Cli(i)al I(s"ru)"+r
Name a( Si1(a"ure Case Number
N+"e b0% .......#Pri(" Name a( Si1(a"ure,........................ C+()urre b0% ..........#Pri(" Name 4 Si1(a"ure, ...................
Cli(i)al C++ri(a"+r, PRC I.D No. ________________ Valid Until ____________ C5ie$ Nurse, PRC I.D No. ________________ Valid Until ____________________
PNA No. ______________________ Valid Until ______________________________ PNA No. _______________________ Valid Until _____________________________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: __________________
Please specify Higest Nu!sing Deg!ee "a!ned: ______________________________ Please specify Higest Nu!sing Deg!ee "a!ned: _______________________________
A//r+*e b0% ........#Pri(" Name 4 Si1(a"ure,................ #NO DESI-NATES,
Dea(, PRC I.D No. ________________ Valid Until _______________ PNA No. ______________________ Valid Until ______________________________
ADPCN No. ______________________ Valid Until _______________ Date document is signed: _________________________ Time ___________________
Please specify Higest Nu!sing Deg!ee "a!ned: _______________________________________
SCHOOL
LO-O
ODC F+rm 6
OR SCRUB FORM
NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Aress, !eb-Si"e
#I$ ACCREDITED% B& !HOM AND !HAT LE'EL, I()lusi*e Da"e +$ A))rei"a"i+(,
ACTUAL DELI'ER& i( ........................................................................
H+s/i"al/H+me/L0i(1-I( Cli(i), Mu(i)i/ali"0/Ci"0/Pr+*i()e
Pre/are b0%
Name +$ S"ue(" .............................................. Si1(a"ure +$ S"ue(" ....... ...................................
Da"e
Per$+rme
a(
Time S"ar"e
Pa"ie("2s Name PROCEDURE
PERFORMED
D3R3
Nurse/Mi7i$e
O( Du"0
#Name +(l0,
SUPER'ISED B&
Cli(i)al I(s"ru)"+r
Name a( Si1(a"ure Case Number
#(+" a//li)able $+r
Bir"5i(1/L0i(1-I(
Cli(i)s/H+mes,
N+"e b0% .......#Pri(" Name a( Si1(a"ure,........................ C+()urre b0% ..........#Pri(" Name 4 Si1(a"ure, ...................
Cli(i)al C++ri(a"+r, PRC I.D No. ________________ Valid Until ____________ C5ie$ Nurse, PRC I.D No. ________________ Valid Until ____________________
PNA No. ______________________ Valid Until ______________________________ PNA No. _______________________ Valid Until _____________________________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: __________________
Please specify Higest Nu!sing Deg!ee "a!ned: ______________________________ Please specify Higest Nu!sing Deg!ee "a!ned: _______________________________
A//r+*e b0% ........#Pri(" Name 4 Si1(a"ure,................ #NO DESI-NATES,
Dea(, PRC I.D No. ________________ Valid Until _______________ PNA No. ______________________ Valid Until ______________________________
ADPCN No. ______________________ Valid Until _______________ Date document is signed: _________________________ Time ___________________
Please specify Higest Nu!sing Deg!ee "a!ned: _______________________________________
NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
SCHOOL
LO-O
For deliveries performed in Lying-In and Homes, ONLY
THE CLINICAL INSTRCTOR AN! CLINICAL
COOR!INATOR are RE"IRE! TO SI#N
ODC F+rm 8
DR ACTUAL
DELI'ER& FORM
SCHOOL
LO-O
For deliveries performed in Lying-In and Homes, ONLY
THE CLINICAL INSTRCTOR AN! CLINICAL
COOR!INATOR are RE"IRE! TO SI#N$
ODC F+rm 9
DR ASSIST
PHONE NUMBER/S, Fax Number/s, E-Mail Aress, !eb-Si"e
#I$ ACCREDITED% B& !HOM AND !HAT LE'EL, I()lusi*e Da"e +$ A))rei"a"i+(,
ASSISTED DELI'ER& i( ........................................................................
H+s/i"al/H+me/L0i(1-I( Cli(i), Mu(i)i/ali"0/Ci"0/Pr+*i()e
Pre/are b0%
Name +$ S"ue(" .............................................. Si1(a"ure +$ S"ue(" ..........................................
Da"e
Per$+rme
a(
Time S"ar"e
Pa"ie("2s Name PROCEDURE
PERFORMED
D3R3
Nurse/Mi7i$e
O( Du"0
#Name +(l0,
SUPER'ISED B&
Cli(i)al I(s"ru)"+r
Name a( Si1(a"ure Case Number
#(+" a//li)able $+r
Bir"5i(1 /L0i(1-I(
Cli(i)s/H+mes,
N+"e b0% .......#Pri(" Name a( Si1(a"ure,........................ C+()urre b0% ..........#Pri(" Name 4 Si1(a"ure, ...................
Cli(i)al C++ri(a"+r, PRC I.D No. ________________ Valid Until ____________ C5ie$ Nurse, PRC I.D No. ________________ Valid Until ____________________
PNA No. ______________________ Valid Until ______________________________ PNA No. _______________________ Valid Until _____________________________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: __________________ Please
specify Higest Nu!sing Deg!ee "a!ned: ______________________________ Please specify Higest Nu!sing Deg!ee "a!ned: _______________________________
A//r+*e b0% ........#Pri(" Name 4 Si1(a"ure,................ #NO DESI-NATES,
Dea(, PRC I.D No. ________________ Valid Until _______________ PNA No. ______________________ Valid Until ______________________________
ADPCN No. ______________________ Valid Until _______________ Date document is signed: _________________________ Time ___________________ Please specify Higest Nu!sing Deg!ee
"a!ned: _______________________________________
NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
SCHOOL
LO-O
ODC F+rm :
IMMEDIATE
NE!BORN
CORD CARE
For deliveries performed in Lying-In and Homes, ONLY
THE CLINICAL INSTRCTOR AN! CLINICAL
COOR!INATOR are RE"IRE! TO SI#N
PHONE NUMBER/S, Fax Number/s, E-Mail Aress, !eb-Si"e
#I$ ACCREDITED% B& !HOM AND !HAT LE'EL, I()lusi*e Da"e +$ A))rei"a"i+(,
IMMEDIATE NE!BORN CORD CARE i( ........................................................................
H+s/i"al/H+me/L0i(1-I( Cli(i), Mu(i)i/ali"0/Ci"0/Pr+*i()e
Pre/are b0%
Name +$ S"ue(" .............................................. Si1(a"ure +$ S"ue(" .........................................
Da"e
Per$+rme
a(
Time S"ar"e
Pa"ie("2s Name Immeia"e Ne7b+r( C+r
Care PERFORMED
I(i)a"e 75ere /er$+rme e313
D3R3, Nurser0, NICU, +r H+me
Nurse/Mi7i$e O(
Du"0
#Name +(l0,
SUPER'ISED B&
Cli(i)al I(s"ru)"+r
Name a( Si1(a"ure
Case Number
#(+" a//li)able $+r
Bir"5i(1 H+mes/L0i(1-
I(Cli(i)s/H+mes,
N+"e b0% .......#Pri(" Name a( Si1(a"ure,........................ C+()urre b0% ..........#Pri(" Name 4 Si1(a"ure, ...................
Cli(i)al C++ri(a"+r, PRC I.D No. ________________ Valid Until ____________ C5ie$ Nurse, PRC I.D No. ________________ Valid Until ____________________
PNA No. ______________________ Valid Until ______________________________ PNA No. _______________________ Valid Until _____________________________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: __________________ Please
specify Higest Nu!sing Deg!ee "a!ned: ______________________________ Please specify Higest Nu!sing Deg!ee "a!ned: _______________________________
A//r+*e b0% ........#Pri(" Name 4 Si1(a"ure,................ #NO DESI-NATES,
Dea(, PRC I.D No. ________________ Valid Until _______________ PNA No. ______________________ Valid Until ______________________________
ADPCN No. ______________________ Valid Until _______________ Date document is signed: _________________________ Time ___________________ Please specify Higest Nu!sing Deg!ee
"a!ned: _______________________________________
GENERAL INSTRUCTIONS ON THE USE OF THESE FORMS:
Rule 1: Logic dictates that these fo!s should "e a##lied o$l% to the i$&co!i$g Nusi$g stude$ts i$ Le'els I
a$d II o$l% of Acade!ic (ea )**+&)**, o$-ads u$til thei gaduatio$ a$d u$til $e- issua$ces ae
eleased "% the .oad of Nusi$g/
Rule ): All those fili$g a##licatio$s fo this No'e!"e )**+ Nuse Lice$sue E0a!i$atio$s a$d the succeedi$g
NLEs 1#io to the effecti'it% of these NE2 FORMS3 should all "e acce#ted "% the Ce$tal a$d
Regio$al 4RC Offices -ithout a$% co$ditio$5 If thee ae a$% $oted disce#a$cies o a$% u$to-ad
o"se'atio$s6 the .oad of Nusi$g e7uies a##o#iate docu!e$tatio$ a$d e#oti$g fo! the
es#ecti'e 4RC Offices a$d should "e ecei'ed "% the .oad of Nusi$g u$til afte the last da% of the
NLE5 E'e%thi$g should "e diected as official co!!u$icatio$s to the .oad of Nusi$g/
Rule 8: As a !atte of #olic%6 gaduates ARE NOT TO .E 4ENALI9E: fo a$% disce#a$cies a$d theefoe all
a##licatio$s dul% su"!itted 1o$ ti!e3 MUST .E ACCE4TE:5 The .oad of Nusi$g shall ta;e
$ecessa% actio$s "ased o$ official e#ots ecei'ed "% the sa!e at the Ce$tal Office -ithi$ the
#esci"ed #eiod as set i$ Rule )/
As a ge$eal ule the .oad of Nusi$g su"sci"es to the #i$ci#le of “loco parentis”. The college a$d its
ad!i$istatio$ diectl% i$'ol'ed i$ the cae a$d su#e'isio$ of stude$ts<gaduates ae a$d shall "e
es#o$si"le a$d accou$ta"le to the la-ful authoities5
.OAR: OF NURSING

______________________ CLINICAL ______________________________ Form 3 THE CLINICAL INSTRUCTOR AND Valid Until ADPCN No. Nurse/Midwife On Duty (Name only) SUPERVISED BY Clinical Instructor Name and Signature Noted by: _______(Print Name and Signature)________________________ Concurred by: __________(Print Name & Signature) ___________________ Clinical Coordinator. ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN. Inclusive Date of Accreditation) ACTUAL DELIVERY in ________________________________________________________________________ Hospital/Home/Lying-In Clinic. ______________________ Valid Until _______________ Date document is signed: _________________________ Time ___________________ DR ASSIST COORDINATOR are REQUIRED TO SIGN Please specify Highest Nursing Degree Earned: _______________________________________ SCHOOL LOGO NAME OF SCHOOL COMPLETE BUSINESS ADDRESS .D No.R. _______________________ Valid Until _____________________________ Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: _______________________________ Approved by: ________(Print Name & Signature)________________ (NO DESIGNATES) For deliveries performed in Lying-In and Homes. ONLY ODC Dean. PRC I. E-Mail Address. ODC Form 2 DR ACTUAL DELIVERY FORM SCHOOL LOGO NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S. ________________ Valid Until ____________ Chief Nurse. PRC I. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: ______________________________ PNA No.D No.D No. ________________ Valid Until _______________ PNA No.For deliveries performed in Lying-In and Homes. Fax Number/s. Municipality/City/Province Prepared by: Name of Student ______________________________________________ Date Performed and Time Started Patient’s Name Case Number (not applicable for Birthing/Lying-In Clinics/Homes) Signature of Student _______ ___________________________________ PROCEDURE PERFORMED D. PRC I. ________________ Valid Until ____________________ PNA No. Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL.

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