NCM 116b Checklist of Procedures

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NCM 116B checklist of procedures
bs nursing (Southwestern University PHINMA)
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NCM 116 B CHECKLIST OF PROCEDURES
CARE OF CLIENTS WITH PROBLEMS IN NUTRITION,
AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE,
PERCEPTION AND COORDINATION,
ACUTE AND CHRONIC
Prepared by:
Edelaine M. Aguilar, RN
Elgien D. Rana, RN
Mariele D. Cabana, RN

lOMoARcPSD|36063909
Table of Contents
PROCEDURE PAGE
I. Catheterization 3
II. Nasogastric Tube Feeding 5
III. Colostomy Care 7
IV. Changing of Colostomy Bag 9
V. Cleansing Enema 11
VI. Fecal Impaction Removal 13
VII. Pre-Operative Care 15
VIII. Post-Operative Care 18
IX. Donning a Sterile Gown and Close Gloving 21
X. Preparation of Sterile Field 23
XI. Open Gloving Technique

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NAME: _________________________________________ DATE:__________
COURSE & SECTION: _____________________________ RLE GROUP:____
CHECKLIST ON CATHETERIZATION
PROCEDURE ABLE TO ABLE TO UNABLE TO
PERFORM PERFORM WITH PERFORM
ASSISTANCE
ASSESSMENT
1. Assess the client and check the order.
2. Determine if the procedure is to be a straight or
indwelling catheterization.
3. Assess need for collection of specimen.
PLANNING
4. Wash hands.
5. Select specific type and size of catheter.
6. Assemble all the equipment including catheterization
set, light source, bath blanket or sheet for draping
and extra equipment as individually determined
IMPLEMENTATION
7. Identify the client and explain the procedure.
8. Assist the client to appropriate position
a. Female-Dorsal recumbent
b. Male-Supine with legs slightly abducted.
9. Open the catheterization set and arranges the sterile
field.
10. Set up the receptacle for soiled cleaning swabs.
11. Open the drainage bag and attach to bed.
12. Wear sterile gloves.
13. Attach syringe and test balloon by instilling sterile
water and deflating by withdrawing the water.
14. Connect distal end of catheter to drainage tubing.
15. Clean urinary meatus with antiseptic solution using a
downward stroke.
16. Lubricate the distal portion of the catheter and place
it on a nearby sterile field.

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17. Insert the catheter gently, in rotating motion 2-3

inches in female or 6-9 inches in male; hold the penis
at 45 degree angle until urine flows. Instruct to take a
deep breath upon insertion.
18. Inflate the retention balloon with sterile water.
19. Tape the catheter to the thigh of a female client and
to the lower abdomen for a male client.
20. Place drainage bag below the level of the bladder.
21. Assist the client to a comfortable position.
22. Gather and discard disposable equipment.
23. Wash hands.
EVALUATION
24. Evaluate using the ff. criteria:
a. Indwelling catheter must drain properly or
straight catheter must be inserted and removed
without discomfort.
b. Client must be comfortable
DOCUMENTATION
25. Document the following
a. Date and time.
b. Type and size of catheter.
c. Whether a specimen was obtained,
d. Amount of urine.
e. Description of urine.
f. Client’s response to procedure.
Remarks:
______________________________________________________________________________________________________________________________
_______________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Satisfactory : 90-95%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
Clinical Instructor Student's Signature

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NAME: _________________________________________ DATE:_____________
COURSE & SECTION: _____________________________ RLE GROUP:______
CHECKLIST ON NASOGASTRIC TUBE (NGT) FEEDING
PROCEDURE ABLE TO ABLE TO PERFORM UNABLE

PERFORM WITH ASSISTANCE TO
PERFORM
ASSESSMENT
1. Check physician’s order.
2. Assess bowel sound.
3. Assess client regarding discomfort from tube.
4. Observe insertion site for irritation
PLANNING
5. Prepare the tube feeding at room temperature.
6. Obtain articles/equipment needed
IMPLEMENTATION
8. Place the client to high fowler’s position.
9. Check for tube placement and patency.
10. Infuse feeding:
a. Pinch proximal end of the feeding tube
b. Attach syringe to Nasogastric Tube (NGT) and
aspirate small amount of contents to fill tube.
c. Fill syringe with measured amount of formula.
d. Release tube and hold syringe at 12 inches
above the tube point of insertion into the client;
refill; repeat until the prescribed amount has
been given.
11. Instill 30 ml of water into the Nasogastric Tube
(NGT).
12. Clamp the Nasogastric Tube (NGT) before of all the
water is instilled.

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13. Ask the client o remain in fowler’s position 30

minutes after feeding.
14. Do after-care of articles used.
15. Wash hands
EVALUATION
16. Evaluate client’s tolerance to feeding.
17. Evaluate client’s response to tube feeding.
18. Observe client for complaints of nausea and
vomiting
DOCUMENTATION
19. Record amount, type and time of feeding.
20. Document client’s response and tolerance to tube
feeding
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________

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NAME: _________________________________________ DATE:_____________
CHECKLIST ON COLOSTOMY CARE
PROCEDURE ABLE TO ABLE TO PERFORM UNABLE TO

PERFORM WITH ASSISTANCE PERFORM
ASSESSMENT
1. Assess the appearance of the stoma and the

condition of the bag.
2. Assess the characteristics of fecal waste.
3. Determine client’s knowledge and

understanding of colostomy care
PLANNING
4. Wash hands.
5. Assemble the equipment needed
IMPLEMENTATION
7. Provide privacy.
8. If using toilet, seat client on toilet, with pouch

over toilet; if using bed pan, place the
pouch/bag over the bed pan.
9. Put on disposable gloves.
10. Place linen saver on abdomen around and

below the pouch/bag.
11. Remove clamp on the bottom of bag and place

within easy reach.
12. Unfold end of pouch and allow feces to drain

into bedpan or toilet.
13. Press sides of lower end of pouch together.
14. Squirt asepto syringe with full tap water into

the bottom of the bag.

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15. Roll up the bag and reclamp the bag.
16. Wipe outside pouch with clean, wet washcloth.
17. Remove gloves and discard all equipment

appropriately.
18. Spray room freshener, if needed.
19. Wash hands
EVALUATION
20. .Evaluate the color, consistency and amount of

feces in pouch.
21. Evaluate the condition of the stoma.
22. Evaluate the response and client’s
responsiveness to perform self-care.
DOCUMENTATION
23. Record the color, consistency and amount of

feces.
24. Record the condition of the stoma.
25. Record the client’s response to the procedure.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________

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NAME: _________________________________________ DATE:_____________
CHECKLIST ON CHANGING OF COLOSTOMY BAG
PROCEDURE ABLE TO ABLE TO UNABLE

PERFORM PERFORM WITH TO
ASSISTANCE PERFORM
ASSESSMENT
1. Assess the condition of the stoma and the
surrounding skin.
2. Assess the characteristics of the fecal waste.
PLANNING
3. Wash hands.
4. Assemble the equipment.
IMPLEMENTATION
6. Provide privacy.
7. Place the disposable bed protector under the client’s
hips.
8. Wear clean gloves.
9. Gently remove the soiled plastic stoma bag from the
skin.
10. Discard soiled stoma bag in plastic waste bag.
11. Remove gloves and wash hands.
12. Clean the stoma and skin with warm tap water. Pat
dry.
13. Apply a small amount of lubricant or protective
cream.
14. Trace pattern onto paper back wafer and cut.
15. Attach clean stoma bag to wafer.
16. Remove paper backing from wafer and place over the
stoma.
17. Tape wafer edges down with hypoallergenic tape.

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18. Remove disposable bed protector and discard all

soiled equipment properly.
19. Wash hands
EVALUATION
20. Evaluate the color, amount and consistency of the
feces.
21. Evaluate the condition of the stoma.
22. Evaluate the client’s comfort.
23. Evaluate client’s readiness to perform self-care
DOCUMENTATION
24. Record the amount, consistency, and amount of feces
in the bag.
25. Record the condition of the stoma.
26. Record the client’s comfort.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
10

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NAME: _________________________________________ DATE:_____________
CHECKLIST ON ADMINISTERING CLEANSING ENEMA

ASSISTANCE PERFORM
ASSESSMENT
1. Verify doctor’s order.
2. Check client’s ability to retain fluid and tolerate the
activity ordered.
PLANNING
3. Wash hands.
4. Gather all equipment.
IMPLEMENTATION
5. Identify client and explain the procedure.
6. Prepare client by positioning and draping.
7. Put on gloves.
8. Administer enema (use specific procedure for

specific enema)
9. Encouraging client to retain fluid as long as possible.
10. Assist client with bedpan, commode or to the toilet.
11. Help client to a comfortable position.
12. Give client the opportunity to refresh.
13. Replace top bedding, remove bath blanket. Ventilate

the room and leave the client in comfortable
environment.
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EVALUATION
1. Evaluate using the following criteria:
a. Quantity and description of feces.
14. Client’s response; skin color, respirations, pulse rate,

and degree of fatigue.
DOCUMENTATION
15. Record date and time, type of enema, amount of fluid
instilled, results and degree of comfort.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
12

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NAME: _________________________________________ DATE:_____________
CHECKLIST ON FECAL IMPACTION REMOVAL

ASSISTANCE PERFORM
ASSESSMENT
1. Check the physician’s order and client’s chart.
2. Determine the indication of fecal impaction.
3. Assess the status of anus and skin surrounding
buttocks.
PLANNING
4. Wash hands.
5. Assemble the equipment.
IMPLEMENTATION
7. Obtain blood pressure; rate and rhythm of pulse.
8. Position client in side lying position with knees
flexed.
9. Drape client so that only buttocks are exposed.
10. Place linen savers under buttocks.
11. Wear gloves. Lubricate first two gloved hand of
dominant hand.
12. Gently spread buttocks with non-dominant
hand.
13. Instruct client to take slow deep breath
through mouth.
14. Insert index finger into rectum (directed
toward umbilicus) until fecal mass is palpable.
15. Gently break up hardened stool; remove one
piece at a time until all stool is removed.
16. Place stool in bedpan as it is removed.
17. Remove finger, wipe excess lubricant from
perineal area and release buttocks.
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18. Discard articles used.

19. Wash hands.
20. Wear new gloves.
21. Wash, rinse and dry buttocks.
22. Reposition client.
23. Discard gloves and articles used.
24. Spray air freshener at bedside.
25. Wash hands
EVALUATION
26. Evaluate color, consistency and amount of
stool.
27. Evaluate client’s response and tolerance to the
procedure.
DOCUMENTATION
28. Record the color, consistency, and amount of
stool.
29. Record vital signs before and after removal.
30. Record client’s tolerance and response to the
procedure.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
14

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NAME: _________________________________________ DATE:_____________
CHECKLIST ON PRE-OPERATIVE CARE

ASSISTANCE PERFORM
ASSESSMENT
1. Verify type and exact time of surgery.
2. Check to see the operative permit/ informed
consent has been signed.
3. Check the chart for any change or additions in
orders.
PLANNING
4. Shave the area.
5. Wash your hands.
6. Obtain necessary equipment
▪ Bath blanket for draping
▪ Shaving equipment, gloves, basin of warm water,
soap for lather, razor, sterile gauze squares,
cleansing agent, cotton swabs.
▪ Sterile towel to cover area after shaving.
7. Plan area to be shaved.
IMPLEMENTATION
8. Identify the patient.
9. Explain the procedure to patient.
10. Provide privacy.
11. Shave the area:
a. Make sure that water is warm.
b. Shave carefully.
c. Rinse the razor frequently.
d. Wipe off excess hair from the skin.
e. Clean any body orifice or crevice in the
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preparation area using cotton swabs.

f. Blot the skin dry but do not rub
vigorously.
g. Observe the general conditions of the
skin.
12. . Dispose the equipment.
13. Administer enema with doctor’s order or upon
the hospital policy.
14. Administer or assist the patient with oral care.
15. Have the patient remove all items of clothing
including undergarments.
16. Have the patient void or insert a foley catheter
if ordered.
17. Remove nail polish.
18. Remove any make-up.
19. Remove hairpins.
20. Remove all prostheses such as eyeglasses, contact
lenses, hearing aids, partial or complete dentures and
store them appropriately.
21. Remove and secure the patient’s jewelry.
22. Assist in moving the patient to a stretcher after
checking the patient’s identity. Have sufficient
help to move the patient and raise side rails on
the stretcher.
EVALUATION
23. Evaluate using the ff. criteria:
a. All actions or procedures ordered were completed
on time.
b. Patient is ready for surgery on time.
DOCUMENTATION
24. Document all pertinent data
a. Preoperative checklist; completed and signed.
b. Time and mode of transfer to surgery.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
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Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
17

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NAME: _________________________________________ DATE:_____________
CHECKLIST ON POST OPERATIVE CARE

ASSISTANCE PERFORM
ASSESSMENT
1. Receive report from the post anesthesia care unit
(PACU).
2. Make the following observations:
a. Time of arrival
b. Responsiveness
c. Vital signs
d. Skin
e. Dressing
f. IV infusion
g. Catheter
h. Other draining tubes
i. Safety and comfort
PLANNING
3. Plan actions with the Nurse on duty (NOD) to resolve
or monitor problems identified.
4. Wash your hands.
5. Determine the equipment needed
IMPLEMENTATION
6. Make the post operative bed ready to receive the
patient.
a. Provide extra blanket at the head such as pad or
bath towel.
b. Provide extra protection in the middle or put a
turning sheet
7. Obtain and prepare the equipment needed.
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8. Upon arrival of the patient from the operating room

or post anesthesia care unit (PACU), assist in
transferring gently from the stretcher to bed.
9. Maintain a patent airway.
10. Suction excessive mucus from the buccal cavity
especially when gurgling sound is observed.
11. Administer oxygen if needed and/or if with doctor’s
order.
12. Keep the venous line open and maintain intravenous
fluid at ordered rate with the presence of Nurse on
duty (NOD).
13. Inspect the wound for drainage that is connected to
other tubing and reservoir.
14. Take and record vital signs accurately.
15. Gently turn the patient from side to side every 2
hours if the condition permits and if with doctor’s
order.
16. Make the patient comfortable as soon as he/she
regains consciousness by initiating the following
measures:
a. Discontinue oxygen therapy if ordered and
keep environment as normal as possible;
b. Remove damp clothes and extra blankets
and put a new clean gown;
c. Wash the patient’s face and hands and rub
is back;
d. Give mouth wash and return dentures if
any;
e. Place the patient in a semi-fowler’s
position if the condition permits and/or with
doctor’s order; and
f. Allow family to see patient for a few
minutes.
EVALUATION
17. Evaluate for any adverse reaction.
DOCUMENTATION
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18. Document and chart all pertinent data.

19. Refer any findings.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
NAME: _________________________________________ DATE:_____________
CHECKLIST ON DONNING A STERILE GOWN AND CLOSE GLOVING
20

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PERFORM PERFORM WITH PERFORM
ASSISTANCE
1. Inspects the sterility of the gown.
2. Don mask and cap. Carry out surgical hand

scrubbing.
3. Pick up a gown, grasping inside the surface at the

collar.
4. Stand away from the sterile pack and table. Hold

gown at arm’s length away from your body to allow
the gown to unfold partially.
5. Hold the inside part of the gown, open shoulder

seams and insert each hand through armholes.
6. Keeping your upper arms in front of you at shoulder

height, extend hands toward gown cuff. Do not push
hands through cuffs.
7. Having circulating nurse to assist by reaching inner

side of the gown and pulling inner shoulder and
side seams onto your shoulders.
8. With your hands still inside the gown, open the

sterile inner wrapper of the glove on the sterile
field.
9. With your dominant sleeved hand, grasp the cuff of

the gloves for the non-dominant hand and lay it on
the extended non-dominant hand forearm with
palm up.
10. Place the palm of the glove against the sleeved palm
with fingers of the glove facing towards you.
11. Manipulate the glove so that sleeved thumb of the

non-dominant hand is grasping the cuff. With your
dominant hand working through its sleeve, grasp
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the upper side of the gloves’ cuff and stretches the

cuff over the end of cuff of the gown.
12. Slowly extend the fingers into the gloves, making

sure the cuff of the glove remains above the cuff of
the gown sleeve.
13. With the gloved non-dominant hand, puts the glove

on the dominant hand by repeating step 9 and 10.
14. Adjust fit and remove wrinkles of the gloves.
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
NAME: _________________________________________ DATE:_____________
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CHECKLIST ON PREPARATION OF STERILE FIELD

PERFORM PERFORM PERFORM
WITH
ASSISTANCE
1. Select clean work surface above the waist level
2. Wash hands
3. Assemble the supplies
To open wrapped package on a surface
4. Place the pack on the center of the work area.
5. Pull the top flap wrapper between the thumb
and index finger away from you.
6. Open the side flaps opening the top flaps first.
Right hand for the right flap, left for the left flap
7. Pull the innermost flap towards you.
To add sterile item on sterile field
8. Open the sterile item while holding the outside
wrapper.
9. Peel the wrapper onto dominant hand.
10. Place the item 6-8 inches above the sterile
field.
11. Dispose the outer wrapper.
To add liquid solution to a sterile field.
12. Read the label solution and strength three
times.
13. Remove the lid and pour a little amount of
solution outside the sterile area.
14. Pour liquid from 6-8 inches above into the
sterile container in the sterile field.
15. Pour slowly.
16. Avoid reaching over the sterile field.
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Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
NAME: _________________________________________ DATE:_____________
CHECKLIST ON GLOVING TECHNIQUE
24

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PERFORM PERFORM PERFORM
WITH
ASSISTANCE
1. Remove jewelry, particularly rings.
2. Wash hands.
3. Remove outer wrapper, peeling apart sides and
lay it on a clean, flat surface.
4. Open inner wrapper, touching only the outside.
5. Secure both flaps open, Identify right and left
glove.
6. Grasp the inner fold with thumb and first two
fingers of non dominant hand and slip the
hands touching only the inner surface.
7. With dominant gloved hand, slip four fingers
underneath, second gloved cuff. Lift the glove
away from the body. Slide the second hand into
the second glove.
8. Adjust fingers of both Gloved hand
9. Raise gloved hand above waist level
Gloves Disposal
10. Grasp outside of one cuff with other gloved
hand.
11. Pull glove off, turning it inside out.
12. Take fingers of bare hand and tuck remaining
glove cuff. Pull glove off inside out. Discard
receptacle
Remarks:
__________________________________________________________________________________________________________________
___________________________________________________________________
Grade:________
25

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Rating Scale:
Excellent : 96-100%
Very Good : 85-89%
Good : 80-84%
Fair : 75-79%
Poor : 74 & below
___________________ ___________________
26

NCM 116b Checklist of Procedures

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NCM 116B checklist of procedures

bs nursing (Southwestern University PHINMA)

Scan to open on Studocu

Studocu is not sponsored or endorsed by any college or university

NCM 116 B CHECKLIST OF PROCEDURES

CARE OF CLIENTS WITH PROBLEMS IN NUTRITION,

AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE,

PERCEPTION AND COORDINATION,

ACUTE AND CHRONIC

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

II. Nasogastric Tube Feeding 5

III. Colostomy Care 7

IV. Changing of Colostomy Bag 9

VI. Fecal Impaction Removal 13

VII. Pre-Operative Care 15

VIII. Post-Operative Care 18

IX. Donning a Sterile Gown and Close Gloving 21

X. Preparation of Sterile Field 23

XI. Open Gloving Technique

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

NAME: _________________________________________ DATE:__________

COURSE & SECTION: _____________________________ RLE GROUP:____

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

17. Insert the catheter gently, in rotating motion 2-3

Clinical Instructor Student's Signature

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON NASOGASTRIC TUBE (NGT) FEEDING

PROCEDURE ABLE TO ABLE TO PERFORM UNABLE

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

13. Ask the client o remain in fowler’s position 30

Clinical Instructor Student's Signature

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

NAME: _________________________________________ DATE:_____________

COURSE & SECTION: _____________________________ RLE GROUP:______

CHECKLIST ON COLOSTOMY CARE

PROCEDURE ABLE TO ABLE TO PERFORM UNABLE TO

1. Assess the appearance of the stoma and the

2. Assess the characteristics of fecal waste.

3. Determine client’s knowledge and

5. Assemble the equipment needed

6. Identify the client and explain the procedure.

8. If using toilet, seat client on toilet, with pouch

9. Put on disposable gloves.

10. Place linen saver on abdomen around and

11. Remove clamp on the bottom of bag and place

12. Unfold end of pouch and allow feces to drain

13. Press sides of lower end of pouch together.

14. Squirt asepto syringe with full tap water into

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

15. Roll up the bag and reclamp the bag.

16. Wipe outside pouch with clean, wet washcloth.

17. Remove gloves and discard all equipment

18. Spray room freshener, if needed.

19. Wash hands

20. .Evaluate the color, consistency and amount of

23. Record the color, consistency and amount of

24. Record the condition of the stoma.

25. Record the client’s response to the procedure.

Clinical Instructor Student's Signature

Downloaded by Francis Anthony Aures (aures.francis.gradschool@gmail.com)

NAME: _______________________________ DATE:

COURSE & SECTION: _________________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP:

NAME: _____________________________ DATE:_

COURSE & SECTION: _______________________ RLE GROUP: