O.

R Form 1A
O.R. SCRUB
ATENEO DE ZAMBOANGA UNIVERSITY FORM Minor
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62)0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
SURGICAL SCRUB in ZAMBOANGA CITY MEDICAL CENTER, ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: CALISANG, LEAHNETTE DOVELLE GARCIA Signature of Student__________________

Date Performed Patient’s Name SURGICAL PROCEDURE O.R. Nurse On Duty

SUPERVISED BY:
and Clinical Instructor
PERFORMED Name and Signature
Time Started Name and Signature
Case Number

Noted by: Approved by:

ANA MARIA BINARAO-LEGARDE, RN MN MARIA LORNA BELLO-PABER, RN MAN
Clinical Coordinator Dean
PRC I.D. No. 0102812 Valid Until: 2022 PRC I.D. No. 0059150 Valid Until: 2022
PNA I.D. No. 012441 Valid Until: 2019 PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2020

Date document is signed: _______________________ Time: ___________ Date document is signed: _____________________ Time: __________
Highest Degree Earned: MASTER IN NURSING Highest Degree Earned: MASTER OF ARTS IN NURSING