ODC Form 2A

O.R. SCRUB FORM
Major

SCHOOL
LOGO

NAME OF SCHOOL

COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
SURGICAL SCRUB in ________________________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ______________________________________________
Date Performed
and
Time Started

Patient’s INITIALS (only)
Case Number

SURGICAL PROCEDURE
PERFORMED

Noted by: _______________________________________________
(Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________
Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

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

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

ODC Form 2B
O.R. MINOR FORM

SCHOOL
LOGO

NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
SURGICAL SCRUB in ________________________________________________________________________
Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ______________________________________________
Date Performed
and
Time Started

Patient’s INITIALS Only
Case Number

SURGICAL PROCEDURE
PERFORMED

Noted by: _______________________________________________
(Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________
Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

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

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

ODC Form 1A
SCHOOL

ACTUAL DELIVERY FORM

LOGO
NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
ACTUAL DELIVERY in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ______________________________________________
Date Performed
and
Time Started

Patient’s INITIAL Only
Case Number

PROCEDURE
PERFORMED

(not applicable for Birthing/LyingIn Clinics/Homes)

Noted by: _______________________________________________
(Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________
Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

D.R. Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not
Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

SCHOOL
ODC Form 1B
ASSISTED DELIVERY

LOGO

FORM

NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
ACTUAL DELIVERY in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ______________________________________________
Date Performed
and
Time Started

Patient’s INITIAL Only
Case Number
(not applicable for Birthing/LyingIn Clinics/Homes)

PROCEDURE
PERFORMED
ASSISTED DELIVERY

Noted by: _______________________________________________
(Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________
Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

D.R. Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not
Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

ODC Form 1C

SCHOOL

CORD CARE FORM

LOGO
NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ______________________________________________
Date Performed
and
Time Started

Patient’s INITIAL Only
Case Number
(not applicable for Birthing
Homes/Lying-In Clinics/Homes)

Immediate Newborn Cord Care
PERFORMED
Indicate where performed e.g. D.R., Nursery,
NICU, or Home

Noted by: _______________________________________________
(Print Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________
Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
signature not required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)