Capitol University

College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City (CHED 070: PACUCOA Level 2, June 14, 1982 Manila)

ODC Form 2A
O.R. SCRUB FORM Major

SURGICAL SCRUB in Northern Mindanao Medical Center Hospital, Municipality/City/Province Prepared by: Maria Sol Fontillas Aguirre
____________________________ Year of Admission in the BSN Program: Year Graduated in BSN Program: June 2006 October 2009

Printed Name and Signature of Student:

No.
1

Date Performed

Time Started

Case No.

Patients Name

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name & Signature)

Supervised by Name and Signature of C.I.

2 3 4 5

Noted by: ________ Mrs. Jenny R. Balo, R.N., M.A.N._____________ (Print Name & Signature) Clinical Coordinator, PRC I.D. No.: _0257481__ Valid Until: June 20, 2012_ Date Document is signed: __________________ Time: _________________ Highest Nursing Degree Earned: ___R.N., M.A.N.____

Approved by: ______ Mrs. Fidela B. Ansale, R.N., M.A.N._______ (Print Name & Signature) Dean, PRC I.D. No.: ____0085045____ Valid Until: February 7, 2010_

Date Document is signed: ____________ Time: ____________________ Highest Nursing Degree Earned: ___B.S.N., M.A.N.____

ODC Form 2C
O.R. SCRUB FORM Minor

Capitol University
College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City (CHED 070: PACUCOA Level 2, June 14, 1982 Manila)

SURGICAL SCRUB in Northern Mindanao Medical Center/ Cagayan de Oro Medical Center/ Capitol University Medical City Hospital, Municipality/City/Province Prepared by: Maria Sol Fontillas Aguirre
____________________________ Patients Name Year of Admission in the BSN Program: Year Graduated in BSN Program: O.R. Nurse On Duty (Name & Signature) June 2006 October 2009 Supervised by Name and Signature of C.I.

Printed Name and Signature of Student: Time Started

No.
1 2 3 4

Date Performed

Case No.

SURGICAL PROCEDURE PERFORMED

Noted by: _________ Mrs. Jenny R. Balo, R.N., M.A.N.____________ (Print Name & Signature) Clinical Coordinator, PRC I.D. No.: _0257481__ Valid Until: June 20, 2012_ Date Document is signed: __________________ Time: _________________ Highest Nursing Degree Earned: ___R.N., M.A.N.____

Approved by: ______ Mrs. Fidela B. Ansale, R.N., M.A.N._______ (Print Name & Signature) Dean, PRC I.D. No.: ____0085045____ Valid Until: February 7, 2010_

Date Document is signed: ____________ Time: ____________________ Highest Nursing Degree Earned: ___B.S.N., M.A.N.____

Capitol University

ODC Form 2B
O.R. CIRCULATING FORM

College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City (CHED 070: PACUCOA Level 2, June 14, 1982 Manila)

SURGICAL SCRUB in Northern Mindanao Medical Center/ Capitol University Medical City Hospital, Municipality/City/Province

Prepared by:

Maria Sol Fontillas Aguirre

____________________________ SURGICAL PROCEDURE PERFORMED

Year of Admission in the BSN Program: Year Graduated in BSN Program: O.R. Nurse On Duty (Name & Signature)

June 2006 October 2009

Printed Name and Signature of Student: Date Performed Time Started

No.
1 2 3 4 5

Case No.

Patients Name

Supervised by Name and Signature of C.I.

Noted by: _________ Mrs. Jenny R. Balo, R.N., M.A.N.____________ (Print Name & Signature) Clinical Coordinator, PRC I.D. No.: _0257481__ Valid Until: June 20, 2012_ Date Document is signed: __________________ Time: _________________ Highest Nursing Degree Earned: ___R.N., M.A.N.____

Approved by: ______ Mrs. Fidela B. Ansale, R.N., M.A.N._______ (Print Name & Signature) Dean, PRC I.D. No.: ____0085045____ Valid Until: February 7, 2010_

Date Document is signed: ____________ Time: ____________________ Highest Nursing Degree Earned: ___B.S.N., M.A.N.____