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Student’s Name:

Date: Year/Block/Group: Area of Assignment:

Clinical Instructor:

ACTIVITY TITLE

DESCRIPTION OF THE ACTIVITY

TYPE OF THERAPY AND CONCEPT:

PREPARATIONS:

PRECAUTIONS:

ACTIVITY Date Effective Date Revised Prepared By: Approved by:

SY 2021-2022 APRIL 2022 LOURDES OHDETTE PELAGIO DR. ALMIRA A. TENORIO, RN, MAN, MAEd
Dean
TOOLS AND MATERIALS:

MECHANICS OF THE ACTIVITY:

ACTIVITY SEQUENCE:

STEP 1

STEP 2

VALUES, BELIEFS, AND SPIRITUALITY DEVELOPED IN THE ACTIVITY

ACTIVITY Date Effective Date Revised Prepared By: Approved by:

SY 2021-2022 APRIL 2022 LOURDES OHDETTE PELAGIO DR. ALMIRA A. TENORIO, RN, MAN, MAEd
Dean

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