Calayan Educational Foundation, Inc.

Office of the College of Nursing

PACUCOA Level III Accredited

DEED OF UNDERTAKING/INFORMED CONSENT

I, a student at Calayan Educational Foundation, Inc. (CEFI), Lucena City taking up

, of legal age, residing at , and hereinafter referred to as
NURSING STUDENT, am voluntarily attending limited face to face classes/activities/trainings scheduled
by the CALAYAN EDUCATIONAL FOUNDATION, INC., despite the risk of infection from the COVID-19
virus, pursuant to Commission on Higher Education-Department of Health (CHED-DOH) Joint
memorandum Circular No. 001-2021.

Said face to face classes/activities/trainings shall include Related Learning Experience (clinical duty and
skills laboratory) for the following subject/s stipulated in Commission on Higher Education (CHED) Memo
No. 15, series of 2017, to wit:

a)
b)
c)
d)
WITNESSETH:

THAT NURSING STUDENT undertakes to abide by the rules and regulations and safety and health
protocols promulgated by CEFI for minimizing the risk of infection from COVID-19 during classes/training.
Said rules, regulations, safety, and health protocols include but are not limited to maintaining/following foot
traffic, wearing of proper personal protective equipment, filling-up a health/declaration form and being
subjected to temperature scan.

THAT NURSING STUDENT undertakes to comply with the requirements required by the school and
hospital (like RT-PCR or antigen test if required, PhilHealth Membership with updated payments, etc.)
before exposure to Related Learning Experience (RLE) rotation (clinical duty and skills laboratory).

THAT NURSING STUDENT undertakes to comply with the requirements set by the Nursing Department
during training such as: bringing of own personal hygiene kit containing the following: ethyl alcohol (70%)
or hand sanitizer, cleansing wipes/tissue paper/toilet paper/hand towel, extra face mask, and hand soap;
wearing of white uniform (Type B), laboratory gown and gloves during the execution of procedures;
bringing own food, observe silence or “No Talking Policy” unless needed, and not loitering anywhere, and
observing proper physical distancing.

THAT NURSING STUDENT concedes that should he/she fail to follow CEFI’s rules, regulations, safety,
and health protocols or fail to exercise ordinary diligence and/or observe precautionary measures to
prevent injury or damage to himself/herself or to avoid contracting the virus, or should damage or injury or
infection occur due to fortuitous events or after having exercised all necessary precautions, Nursing
Student shall not hold CEFI or any of its officers or employees liable for whatever damage or injury that
may be caused to himself/herself.

THAT during training/clinical duty, NURSING STUDENT shall handle all equipment/supplies borrowed
from the hospital with utmost care. All losses and breakages/damages, inclusive of injuries to third parties,
due to NURSING STUDENT’S negligence shall be the NURSING STUDENT’S sole liability. Whatever
amount CEFI shall be made liable to pay due to NURSING STUDENT’S negligence shall be reimbursed to
CEFI by said NURSING STUDENT or his/her parent/s or guardian.

THAT NURSING STUDENT and/or his/her parent/s or guardian shall hold CALAYAN EDUCATIONAL
FOUNDATION, INC. (CEFI), free and harmless from any liability arising from NURSING STUDENT’S
training/RLE with the affiliating hospital.

Student’s Name and Signature

With the consent of the parent/guardian:

Signature over printed name of parent/guardian

CALAYAN EDUCATIONAL FOUNDATION, INC.

Maharlika Highway, Lucena City, Philippines • Tel. No. +63 (042) 710-2514 loc 108
www.cefi.edu.ph