ODC Form 2A

UNIVERSITY OF ILOILO O.R. SCRUB FORM

Rizal St., Iloilo City MAJOR
Tel. No. (033) 338-1071 loc. 146
SURGICAL SCRUB in _____________________________________________________________________________________________
Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed SUPERVISED BY

Patient’s Initial Only SURGICAL PROCEDURE O.R Nurse on Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

Noted by : ____________________________________________________________ Approved by:__________________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean,PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time___________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________
 ODC Form 2B
UNIVERSITY OF ILOILO O.R. CIRCULATING FORM
Rizal St., Iloilo City
Tel. No. (033) 338-1071 loc. 146
SURGICAL SCRUB in _____________________________________________________________________________________________
Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed SUPERVISED BY

Patient’s Initial Only SURGICAL PROCEDURE O.R Nurse on Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

Noted by : ____________________________________________________________ Approved by:__________________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean,PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time___________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________
 ODC Form 2B
UNIVERSITY OF ILOILO O.R. CIRCULATING FORM
Rizal St., Iloilo City
Tel. No. (033) 338-1071 loc. 146

SURGICAL SCRUB in _____________________________________________________________________________________________

Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

Noted by: _____________________________________________________________ Approved by: __________________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean, PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time___________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________
 ODC Form 2A
UNIVERSITY OF ILOILO O.R. SCRUB FORM
Rizal St., Iloilo City MAJOR
Tel. No. (033) 338-1071 loc. 146

SURGICAL SCRUB in _____________________________________________________________________________________________

Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

Noted by: _____________________________________________________________ Approved by: __________________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean, PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time___________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________
 ODC Form 2A
UNIVERSITY OF ILOILO O.R. SCRUB FORM
Rizal St., Iloilo City MAJOR
Tel. No. (033) 338-1071 loc. 146

SURGICAL SCRUB in _____________________________________________________________________________________________

Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

Noted by: _____________________________________________________________ Approved by: __________________________________________________________

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean, PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time___________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________
 DR Form 1B
UNIVERSITY OF ILOILO ASSISTED DELIVERY FORM
Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ASSISTED DELIVERY in _________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, (Name and Signature)
(not applicable for Birthing/Lying- signature not required)
In Clinics/Homes)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________

(Print Name and Signature) (Print Name and Signature)
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:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:____________________________________________
 DR Form 1B
UNIVERSITY OF ILOILO ASSISTED DELIVERY FORM
Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ASSISTED DELIVERY in _________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, (Name and Signature)
(not applicable for Birthing/Lying- signature not required)
In Clinics/Homes)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________

(Print Name and Signature) (Print Name and Signature)
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:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:____________________________________________
 DR Form 1A
UNIVERSITY OF ILOILO ACTUAL DELIVERY FORM
Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ACTUAL DELIVERY in __________________________________________________________

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

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, (Name and Signature)
(not applicable for Birthing/Lying- signature not required)
In Clinics/Homes)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________

(Print Name and Signature) (Print Name and Signature)
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:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:_____________________________________________
 DR Form 1A
UNIVERSITY OF ILOILO ACTUAL DELIVERY FORM
Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ACTUAL DELIVERY in __________________________________________________________

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

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, (Name and Signature)
(not applicable for Birthing/Lying- signature not required)
In Clinics/Homes)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________

(Print Name and Signature) (Print Name and Signature)
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:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:_____________________________________________
 DR Form 1A
UNIVERSITY OF ILOILO ACTUAL DELIVERY FORM
Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ACTUAL DELIVERY in __________________________________________________________

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

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, (Name and Signature)
(not applicable for Birthing/Lying- signature not required)
In Clinics/Homes)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________

(Print Name and Signature) (Print Name and Signature)
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:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:_____________________________________________