prc form. i think theres a new one.

1. ODC Form 2A O.R. SCRUB FORM Major<br />VISAYAS STATE UNIVERSITY<br />ViSCA, BAYBAY, LEYTE 6521 - A<br />(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph<br />ACCREDITED: AACCUP LEVEL II, November 22-26, 2010<br />SURGICAL SCRUB in ________________________________________________________________________<br />Hospital, Municipality/City/Province<br />Prepared by: <br />Printed Name with Signature of Student ______________________________________________<br />Date PerformedandTime StartedPatient’s INITIALS (only)SURGICAL PROCEDUREPERFORMEDO.R. Nurse On Duty(Name AND Signature)SUPERVISED BYClinical InstructorName and SignatureCase Number<br />Noted by: _______________________________________________ Approved by: ___________________________________________________ (Print Name and Signature) (Print Name and Signature) <br />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 Nursing Degree Earned: ________________________________ Specify Highest Nursing Degree Earned: _______________________________________ <br />(STRICTLY NO DESIGNATES)<br />ODC Form 2B O.R. MINOR FORM<br />VISAYAS STATE UNIVERSITY<br />ViSCA, BAYBAY, LEYTE 6521 - A<br />(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph<br />ACCREDITED: AACCUP LEVEL II, November 22-26, 2010<br />SURGICAL SCRUB in ________________________________________________________________________<br />Hospital, Municipality/City/Province<br />Prepared by: <br />Printed Name with Signature of Student ______________________________________________<br />Date PerformedandTime StartedPatient’s INITIALS (only)SURGICAL PROCEDUREPERFORMEDO.R. Nurse On Duty(Name and Signature)SUPERVISED BYClinical InstructorName and SignatureCase Number<br />Noted by: _______________________________________________ Approved by: ___________________________________________________ (Print Name and Signature) (Print Name and Signature) <br />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 Nursing Degree Earned: ________________________________ Specify Highest Nursing Degree Earned: _______________________________________ <br />(STRICTLY NO DESIGNATES)<br />ODC Form 1A ACTUAL DELIVERY FORM<br />VISAYAS STATE UNIVERSITY<br />ViSCA, BAYBAY, LEYTE 6521 - A<br />(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph<br />ACCREDITED: AACCUP LEVEL II, November 22-26, 2010<br />SURGICAL SCRUB in ________________________________________________________________________<br />Hospital, Municipality/City/Province<br />Prepared by: <br />Printed Name with Signature of Student ______________________________________________<br />Date PerformedandTime StartedPatient’s INITIALS (only)PROCEDUREPERFORMEDD.R. Nurse On Duty(Name and Signature)(If Midwife on Duty, Signature Not Required)SUPERVISED BYClinical InstructorName and SignatureCase Number(not applicable for Birthing/Lying In Clinics/Homes)<br />Noted by: _______________________________________________ Approved by: ___________________________________________________ (Print Name and Signature) (Print Name and Signature) <br />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 Nursing Degree Earned: ________________________________ Specify Highest Nursing Degree Earned: _______________________________________ <br />(STRICTLY NO DESIGNATES)<br />ODC Form 1B ASSISTED DELIVERY FORM<br />VISAYAS STATE UNIVERSITY<br />ViSCA, BAYBAY, LEYTE 6521 - A<br />(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph<br />ACCREDITED: AACCUP LEVEL II, November 22-26, 2010<br />SURGICAL SCRUB in ________________________________________________________________________<br />Hospital, Municipality/City/Province<br />Prepared by: <br />Printed Name with Signature of Student ______________________________________________<br />Date PerformedandTime StartedPatient’s INITIALS (only)PROCEDUREPERFORMEDASSISTED DELIVERYD.R. Nurse On Duty(Name and Signature)(If Midwife on Duty, Signature Not Required)SUPERVISED BYClinical InstructorName and SignatureCase Number(not applicable for Birthing/Lying In Clinics/Homes)<br />Noted by: _______________________________________________ Approved by: ___________________________________________________ (Print Name and Signature) (Print Name and Signature) <br />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 Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: _______________________________________ <br />(STRICTLY NO DESIGNATES)<br />ODC Form 1C CORD CARE FORM<br />VISAYAS STATE UNIVERSITY<br />ViSCA, BAYBAY, LEYTE 6521 - A<br />(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph<br />ACCREDITED: AACCUP LEVEL II, November 22-26, 2010<br />SURGICAL SCRUB in ________________________________________________________________________<br />Hospital, Municipality/City/Province<br />Prepared by: <br />Printed Name with Signature of Student ______________________________________________<br />Date PerformedandTime StartedPatient’s INITIALS (only)Immediate Newborn Cord CarePERFORMEDIndicate where performed e.g. D.R., Nursery, NICU, or HomeD.R. Nurse On Duty(Name and Signature)(If Midwife on Duty, Signature Not Required)SUPERVISED BYClinical InstructorName and SignatureCase Number(not applicable for Birthing/Lying In Clinics/Homes)<br />Noted by: _______________________________________________ Approved by: ___________________________________________________ (Print Name and Signature) (Print Name and Signature) <br />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 Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: _______________________________________<br />(STRICTLY NO DESIGNATES)<br />