OUR LADY OF FATIMA UNIVERSITY 120 McArthur Highway, Valenzuela City Tel.

432-6026/293-2703 to 06 PACUCOA Level II Accredited SURGICAL SCRUB NURSE in PASO DE BLAS LYING IN CLINIC Prepared by: Printed Name and Signature of Student____________________________________________

Date Performed and Time Started

Patient's INITIAL Only SURGICAL PROCEDURE PERFORMED Case Number

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

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ____________________________________ Aida V. Garcia, RN MAN Clinical Coordinator, PRC I.D. No. 0196716 Valid Until MARCH 2011 Date document is signed: _______________ Time __________ Degree Earned: Master of Arts in Nursing

Approved by: ____________________________________________________ Lurceli L. Santos, RM RN MAN Dean, PRC I.D. No. 0010878 Valid Until 2011 Date document is signed: _______________ Time _______ Degree Earned: Master of Arts in Nursing

OUR LADY OF FATIMA UNIVERSITY 120 McArthur Highway, Valenzuela City Tel. 432-6026/293-2703 to 06 PACUCOA Level II Accredited SURGICAL CIRCULATING NURSE in PASO DE BLAS LYING IN CLINIC

Prepared by: Printed Name and Signature of Student____________________________________________ SURGICAL PROCEDURE PERFORMED

Date Performed and Time Started

Patient's INITIAL Only Case Number

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

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ____________________________________ Aida V. Garcia, RN MAN Clinical Coordinator, PRC I.D. No. 0196716 Valid Until MARCH 2011 Date document is signed: _______________ Time __________ Degree Earned: Master of Arts in Nursing

Approved by: ____________________________________________________ Lurceli L. Santos, RM RN MAN Dean, PRC I.D. No. 0010878 Valid Until 2011 Date document is signed: _______________ Time _______ Degree Earned: Master of Arts in Nursing

OUR LADY OF FATIMA UNIVERSITY 120 McArthur Highway, Valenzuela City Tel. 292-1124 PACUCOA Level II. Granted April 10, 2002 ACTUAL DELIVERY in PASO DE BLAS LYING IN CLINIC Prepared by: Printed Name and Signature of Student____________________________________________
D.R. Nurse On Duty (Name and Signature) (If Midwife on duty, Signature Not Required)

Date Performed and Time Started

Patient's INITIAL Only Case Number

PROCEDURE PERFORMED

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ____________________________________ Aida V. Garcia, RN MAN Clinical Coordinator, PRC I.D. No. 0196716 Valid Until MARCH 2011 Date document is signed: _______________ Time _____________ Degree Earned: Master of Arts in Nursing

Approved by: ____________________________________________________ Lurceli L. Santos, RM RN MAN Dean, PRC I.D. No. 0010878 Valid Until 2011 Date document is signed: _______________ Time _______ Degree Earned: Master of Arts in Nursing

OUR LADY OF FATIMA UNIVERSITY 120 McArthur Highway, Valenzuela City Tel. 432-6026/293-2703 to 06 PACUCOA Level II Accredited ASSISTED DELIVERY in PASO DE BLAS LYING IN CLINIC Prepared by: Printed Name and Signature of Student____________________________________________
Date Performed and Time Started Patient's INITIAL Only Case Number ASSISTED DELIVERY PROCEDURE PERFORMED D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ____________________________________ Aida V. Garcia, RN MAN Clinical Coordinator, PRC I.D. No. 0196716 Valid Until MARCH 2011 Date document is signed: _______________ Time __________ Degree Earned: Master of Arts in Nursing

Approved by: ____________________________________________________ Lurceli L. Santos, RM RN MAN Dean, PRC I.D. No. 0010878 Valid Until 2011 Date document is signed: _______________ Time _______ Degree Earned: Master of Arts in Nursing

OUR LADY OF FATIMA UNIVERSITY 120 McArthur Highway, Valenzuela City Tel. 432-6026/293-2703 to 06 PACUCOA Level II Accredited IMMEDIATE NEWBORN CORD CARE in PASO DE BLAS LYING IN CLINIC Prepared by: Printed Name and Signature of Student____________________________________________
Date Performed and Time Started Patient's INITIAL Only Case Number Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU or Home D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not required) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ____________________________________ Aida V. Garcia, RN MAN Clinical Coordinator, PRC I.D. No. 0196716 Valid Until MARCH 2011 Date document is signed: _______________ Time __________ Degree Earned: Master of Arts in Nursing

Approved by: ____________________________________________________ Lurceli L. Santos, RM RN MAN Dean, PRC I.D. No. 0010878 Valid Until 2011 Date document is signed: _______________ Time _______ Degree Earned: Master of Arts in Nursing