OLIVAREZ COLLEGE

Dr. A. Santos Avenue, San Dionisio, Parañaque City

PACUCOA Accredited
COLLEGE OF HEALTH SCIENCES EDUCATION
NURSING DEPARTMENT
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Student Name: ___________________________________________ Score: _________________________

Level and Group No.: ______________________________________ Date: ________________________
Directions: Evaluate each step/task by putting (✔) under the proper heading. A numerical number may also be assigned &a minimum
passing level determined.
Rate the students from 2 - 0, where:
(2) Performed Correctly Students performed the step according to the standard procedure or guidelines
(1) Attempted Not Correctly Students unable to perform the steps/task according to procedure or guidelines
(0) Not Done Students did not do the step/task
(NO) Not Observed (NO) Evaluator unable to observe the step/task for various reasons like interruptions/inattentiveness,.

Checklist on Performing Acetic Acid Test

STEP Performed Performed Not Not

Correctly but not Done Observed
(2) Correctly (0) (NO)
Done (1)

1. Gather and check supplies and equipment.

2. Perform hand washing

3. Ask the client to collect mid stream urine and place it in a
sterile cup.(5-10 ml) and place it in the test tube.
4. Heat the urine until it boils without shaking it until cloudy
5. Drop 2-3 drops of 10%acetic acid, heat again and allow to
cool. observe and interpret the findings (characteristics)
6. Document your findings
Computation for student rating:
Raw score X 60 + 40
Perfect score

Student’s Signature and Date: _____________________________

Signature of Clinical Instructor and Date: ______________________

Remarks:
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