University of Luzon

COLLEGE OF NURSING ODC Form 2A

PEREZ BLVD., DAGUPAN CITY, 2400 SURGICAL SCRUB
Phone No. (075) 515-8177 / Fax No. (075) 515 – 5767 (Major) FORM
Email Address: ulcn@ul.edu.ph WEBSITE: www.ul.edu.ph
Accreditation Granted: Level III First Reaccredited Status
Accreditation Agency: PACUCOA
Inclusive Date of Accreditation: August 2018 – 2023

SURGICAL SCRUB (Major) in LUZON MEDICAL CENTER, DAGUPAN CITY, PANGASINAN

Hospital/Municipality/City/Province

Prepared by:
Printed Name: DELA CRUZ JESTIAN RYLL B. Signature of Student:

Patient’s INITIAL (only) SUPERVISED BY:

Date Performed and SURGICAL PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name and Signature)
Case Number (Name and Signature)

APRIL 15, 2022 A.M.M.R NORALYN D. VISDA

Noted by: DIVINAGRACIA C. CORRIGAN Approved by: ELLEN P. GABRIEL

CLINICAL COORDINATOR DEAN
PRC I.D No. 0094704 Valid Until: PRC I.D No. 0124715 Valid Until:
PNA No.: 2408 Valid Until: Life Member PNA No.: 17448 Valid Until: Life Member
Date Document Signed: Time: Date Document Signed: Time:
Highest Nursing Degree Earned: RN; MAN Highest Nursing Degree Earned: RN; MAN

(STRICTLY NO DESIGNATES)
 University of Luzon ODC Form 2B
COLLEGE OF NURSING CIRCULATING FUNCTION
(Major) FORM
PEREZ BLVD., DAGUPAN CITY, 2400
Phone No. (075) 515-8177 / Fax No. (075) 515 – 5767
Email Address: ulcn@ul.edu.ph WEBSITE: www.ul.edu.ph
Accreditation Granted: Level III First Reaccredited Status
Accreditation Agency: PACUCOA
Inclusive Date of Accreditation: August 2018 – 2023

CIRCULATING FUNCTION (Major) in REGION 1 MEDICAL CENTER

Hospital/Municipality/City/Province

Prepared by:
Printed Name: DELA CRUZ JESTIAN RYLL B. Signature of Student:

Patient’s INITIAL (only) SUPERVISED BY:

Date Performed and SURGICAL PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name and Signature)
Case Number (Name and Signature)

Noted by: DIVINAGRACIA C. CORRIGAN Approved by: ELLEN P. GABRIEL

CLINICAL COORDINATOR DEAN
PRC I.D No. 0094704 Valid Until: PRC I.D No. 0124715 Valid Until:
PNA No.: 2408 Valid Until: Life Member PNA No.: 17448 Valid Until: Life Member
Date Document Signed: Time: Date Document Signed: Time:
Highest Nursing Degree Earned: RN; MAN Highest Nursing Degree Earned: RN; MAN

(STRICTLY NO DESIGNATES)