PILAR COLLEGE OF ZAMBOANGA CITY, INC.

P.O. Box 283 DOC Form 2B

R.T. Lim Boulevard, Zamboanga City, 7000 OPERATING ROOM
CIRCULATING FORM
PHILIPPINES
OPERATING ROOM CIRCULATING

SURGICAL SCRUB in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and SURGICAL PROCEDURE PERFORMED O.R. Nurse on duty Supervised by
Time Started (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing
 PILAR COLLEGE OF ZAMBOANGA CITY, INC.
P.O. Box 283 DOC Form 2A
R.T. Lim Boulevard, Zamboanga City, 7000 OPERATING ROOM
MAJOR FORM
PHILIPPINES
OPERATING ROOM MAJOR

SURGICAL SCRUB in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty Supervised by
Time Started (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing
 PILAR COLLEGE OF ZAMBOANGA CITY, INC.
P.O. Box 283 DOC Form 2A
R.T. Lim Boulevard, Zamboanga City, 7000 OPERATING ROOM
MINOR FORM
PHILIPPINES
OPERATING ROOM MINOR

SURGICAL SCRUB in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty Supervised by
Time Started (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing
 PILAR COLLEGE OF ZAMBOANGA CITY, INC.
P.O. Box 283 DOC Form 1C
R.T. Lim Boulevard, Zamboanga City, 7000 CORD CARE FORM

PHILIPPINES
CORD CARE

ACTUAL DELIVERY in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and IMMEDIATE NEWBORN CORD CARE D.R. Nurse on Duty Supervised by
Time Started PERFORMED (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing

PILAR COLLEGE OF ZAMBOANGA CITY, INC.

DOC Form 1B
ASSISTED DELIVERY
FORM
 P.O. Box 283
R.T. Lim Boulevard, Zamboanga City, 7000
PHILIPPINES
ASSISTED DELIVERY

ACTUAL DELIVERY in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and PROCEDURE PERFORMED D.R. Nurse on Duty Supervised by
Time Started (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing

PILAR COLLEGE OF ZAMBOANGA CITY, INC.

P.O. Box 283 DOC Form 1A or
ACTUAL DELIVERY
FORM
 R.T. Lim Boulevard, Zamboanga City, 7000
PHILIPPINES
ACTUAL DELIVERY
ACTUAL DELIVERY in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and PROCEDURE PERFORMED D.R. Nurse on Duty Supervised by
Time Started (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing

PILAR COLLEGE OF ZAMBOANGA CITY, INC.

P.O. Box 283 DOC Form 1A or
R.T. Lim Boulevard, Zamboanga City, 7000 ACTUAL DELIVERY
FORM
 PHILIPPINES
ACTUAL DELIVERY
ACTUAL DELIVERY in Zamboanga City Medical Center

Prepared by:
Name and Signature of Student:

Patient’s Name
Date Performed and PROCEDURE PERFORMED D.R. Nurse on Duty Supervised by
Time Started (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: MARLENE D. VALERA, MAN, RN Approved by: MA. JOCELYN L. TORIBIO, MAN, RN
Clinical Coordinator, PRC I.D. No. 0178006 Valid Until: February 26, 2023 Dean, PRC I.D. No. 0146296 Valid Until: March 24, 2023
Date document signed: ________________Time: _______________ Date document signed: _____________ Time: _________
Highest Nursing Degree Earned: Master of Arts in Nursing Highest Nursing Degree Earned: Master of Arts in Nursing