Bulacan State University COLLEGE OF NURSING

Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com

NAME OF STUDENT: Name of School: Bulacan State University Address of School: Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: Year Graduated from the BSN Program:

SURGICAL SCRUB in _____________________________________________________________ Hospital, Municipality/ City/ Province Date Performed and Time Started Patients INITIALS (only) CASE NUMBER SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty ( Name and Signature)

O.R. FORM 1A
MAJOR O.R. SCRUB FORM Supervised by Clinical Instructor (Name and Signature)

Signature over Printed Name CTC Number:_____________ Date :____________________ Place:____________________

Clinical Coordinator

Student

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:________

Dean

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:____ Valid Until:________ PNA No:____ Valid Until:________ ADPCN No:__ Valid Until:________

Bulacan State University COLLEGE OF NURSING

Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: Name of School: Bulacan State University Address of School: Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: Year Graduated from the BSN Program:

SURGICAL SCRUB in _____________________________________________________________ Hospital, Municipality/ City/ Province Date Performed and Time Started Patients INITIALS (only) CASE NUMBER SURGICAL PROCEDURE PERFORMED

O.R. FORM 1B
MAJOR O.R. CIRCULATING FORM Supervised by Clinical Instructor (Name and Signature)

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

Signature over Printed Name CTC Number:_____________ Date :____________________ Place:____________________

Clinical Coordinator

Student

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:________

Dean

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:____ Valid Until:________ PNA No:____ Valid Until:________ ADPCN No:__ Valid Until:________

Bulacan State University COLLEGE OF NURSING

Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: Name of School: Bulacan State University Address of School: Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: Year Graduated from the BSN Program:

SURGICAL SCRUB in _____________________________________________________________ Hospital, Municipality/ City/ Province Date Performed and Time Started Patients INITIALS (only) CASE NUMBER SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty ( Name and Signature)

O.R. FORM 1C
MINOR FORM Supervised by Clinical Instructor (Name and Signature)

Clinical Coordinator

Student

Signature over Printed Name CTC Number:_____________ Date :____________________ Place:____________________

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:________

Dean

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:____ Valid Until:________ PNA No:____ Valid Until:________ ADPCN No:__ Valid Until:________

Bulacan State University COLLEGE OF NURSING

Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: Name of School: Bulacan State University Address of School: Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: Year Graduated from the BSN Program:

ACTUAL DELIVERY SCRUB in _____________________________________________________________ D.R. FORM 1D Hospital, Municipality/ City/ Province ACTUAL DELIVERY FORM Date Performed and Time Started Patients INITIALS (only) CASE NUMBER PROCEDURE PERFORMED D.R. Nurse On Duty ( Name and Signature) Supervised by Clinical Instructor (Name and Signature)

Signature over Printed Name CTC Number:_____________ Date :____________________ Place:____________________

Clinical Coordinator

Student

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:________

Dean

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:_____ Valid Until:________ ADPCN No:____ Valid Until:________

Bulacan State University COLLEGE OF NURSING

Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: Name of School: Bulacan State University Address of School: Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: Year Graduated from the BSN Program:

IMMEDIATE NEWBORN CORD CARE in _____________________________________________________________ Hospital, Municipality/ City/ Province Date Performed and Time Started Patients INITIALS (only) CASE NUMBER Immediate Newborn Cord Care Performed

ICNB FORM 1E
IMMEDIATE CARE OF THE NEWBORN FORM

Nurse On Duty ( Name and Signature)

Supervised by Clinical Instructor (Name and Signature)

Signature over Printed Name CTC Number:_____________ Date :____________________ Place:____________________

Clinical Coordinator

Student

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:______ Valid Until:________ PNA No:______ Valid Until:________

Dean

Signature over Printed Name Degree:_________________ Date Signed:_____________ PRC No:____ Valid Until:________ PNA No:____ Valid Until:________ ADPCN No:_____Valid Until:________