ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
Tel. No. (033)338-2830

SURGICAL SCRUB in _____________________________________________________________

Hospital, Municipality/City/Province

Prepared by: O.R. Form 1A

O.R. SCRUB FORM
Major
_______________________________________________________
Printed Name and Signature of Student

Date Performed Patient’s INITIALS Only SUPERVISED BY:

and
SURGICAL PROCEDURE O.R. Nurse On Duty
Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number (Name and Signature)

Noted by: ________________________________________________________________ Approved by:_____________________________________________________

Clinical Coordinator, PRC I.D. No. ______________ Valid until: __________________ Dean, PRC I.D. No. __________________ Valid until: __________________
Date document is signed:________________________ Time: _____________________ Date document is signed: _____________ Time:_______________________
Highest Nursing Degree Earned: ______________________________________________ Highest Nursing Degree Earned: _____________________________________
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
Tel. No. (033)338-2830

SURGICAL SCRUB in _____________________________________________________________

Hospital, Municipality/City/Province

Prepared by: O.R. Form 1B

O.R. CIRCULATING
FORM
_______________________________________________________
Printed Name and Signature of Student

Date Performed Patient’s INITIALS Only SUPERVISED BY:

and
SURGICAL PROCEDURE O.R. Nurse On Duty
Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number (Name and Signature)

Noted by: ________________________________________________________________ Approved by:_____________________________________________________

Clinical Coordinator, PRC I.D. No. ______________ Valid until: __________________ Dean, PRC I.D. No. __________________ Valid until: __________________
Date document is signed:________________________ Time: _____________________ Date document is signed: _____________ Time:_______________________
Highest Nursing Degree Earned: ______________________________________________ Highest Nursing Degree Earned: _____________________________________
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
Tel. No. (033)338-2830

ACTUAL DELIVERY in _____________________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by: D.R. Form

ACTUAL DELIVERY FORM
_______________________________________________________
Printed Name and Signature of Student

Patient’s INITIALS Only

D.R. Nurse On Duty
Date Performed SUPERVISED BY:
and
PROCEDURE (Name and Signature)
Clinical Instructor
Case Number PERFORMED (If Midwife on Duty, Signature Not
Time Started (not applicable for Birthing/Lying-In (Name and Signature)
Required)
Clinics/Homes)

Noted by: ________________________________________________________________ Approved by:_____________________________________________________

Clinical Coordinator, PRC I.D. No. ______________ Valid until: __________________ Dean, PRC I.D. No. __________________ Valid until: __________________
Date document is signed:________________________ Time: _____________________ Date document is signed: _____________ Time:_______________________
Highest Nursing Degree Earned: ______________________________________________ Highest Nursing Degree Earned: _____________________________________
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
Tel. No. (033)338-2830

IMMEDIATE NEWBORN CORD CARE in _________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by: ICNB Form

IMMEDIATE CARE OF THE
NEWBORN FORM
_______________________________________________________
Printed Name and Signature of Student

Patient’s INITIALS Only

IMMEDIATE NEWBORN CORD CARE Nurse On Duty
Date Performed SUPERVISED BY:
(Name and Signature)
and Case Number PERFORMED (If Midwife on Duty, Signature Not
Clinical Instructor
Time Started (not applicable for Birthing/Lying-In Indicate where performed e.g. D.R., Nursery, NICU, or Home (Name and Signature)
Required)
Clinics/Homes)

Noted by: ________________________________________________________________ Approved by:_____________________________________________________

Clinical Coordinator, PRC I.D. No. ______________ Valid until: __________________ Dean, PRC I.D. No. __________________ Valid until: __________________
Date document is signed:________________________ Time: _____________________ Date document is signed: _____________ Time:_______________________
Highest Nursing Degree Earned: ______________________________________________ Highest Nursing Degree Earned: _____________________________________