ARELLANO UNIVERSITY COLLEGE of NURSING 2600 Legarda St.

, Sampaloc, Manila 7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ODC Form 2A O.R. SCRUB MAJOR FORM

SURGICAL SCRUB (Major) 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

SURGICAL PROCEDURE PERFORMED

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

SUPERVISED BY Clinical instructor Name and Signature

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Date document is signed: ________________ Time: ______________ Highest Nursing Degree Earned: BSN, MAN

Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013 Date document is signed: ________________ Time: _____________ Highest Nursing Degree Earned: BSN, Midwifery, MAN

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ARELLANO UNIVERSITY COLLEGE of NURSING 2600 Legarda St., Sampaloc, Manila 7347371 LOC 222/210, 7353509 ax, www.arellano.edu.ph PACUCOA Level II Re-Accredited Status ebruary 2010 to ebruary 2015)
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ARELLANO UNIVERSITY COLLEGE of NURSING 2600 Legarda St., Sampaloc, Manila 7347371 LOC 222/210, 7353509 ax, www.arellano.edu.ph PACUCOA Level II Re-Accredited Status ebruary 2010 to ebruary 2015)
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Noted by: LEONARDO M. NUESTRO R., RN, MAN Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Date document is signed: Time: Highest Nursing Degree Earned: BSN, MAN
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Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013 Date document is signed: Time: Highest Nursing Degree Earned: BSN, Midwifery, MAN
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