University of San Agustin

General Luna St., 5000 Iloilo City, Iloilo

Tel. No.: (033) 337-4841 to 44 local 259; Fax No.: (033) 337-4403; E-mail Address: cnnd@usa.edu.ph; Website: www.usa.edu.ph

SURGICAL SCRUB in The Medical City Iloilo, Molo, Iloilo City

Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student

Date Performed and Patient’s Initials only Name and Signature of Name and Signature of
Surgical Procedure Performed
Time Started Case Number Operating Room Nurse on Duty Supervising Clinical Instructor

Noted: Carlane P. Torres, PhD, RN___________________________________________ Approved: Louie P. Hijalda, PhD, RN__________________________________________
Clinical Coordinator, PRC I.D. No. 0317254 Valid Until: March 4, 2025_____________ Dean, PRC I.D. No. 0188653____________ Valid Until: May 9, 2026 ____________
Date document is signed:_____________ Time:_____________________________ Date document is signed:______________ Time:______________________________
Please Specify Highest Nursing Degree Earned: PhD_____________________________ Please Specify Highest Nursing Degree Earned: PhD_____________________________