NAME OF SCHOOL

COMPLETE BUSINESS ADDRESS

PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
SURGICAL SCRUB in ________________________________________________________________________
Hospital, Municipality/City/Province
O.R. Form 1A
Prepared by: O.R. SCRUB FORM
Printed Name with Signature of Student ______________________________________________ Major

Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY

and SURGICAL PROCEDURE (Name AND Signature) Clinical Instructor
Time Started Case Number Name and Signature
PERFORMED

O,R, Form 1B
Prepared by: O.R. CICRUCLATING
Printed Name and Signature of Student ______________________________________________ FORM

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

(STRICTLY NO DESIGNATES)

[These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]
 NAME OF SCHOOL
COMPLETE BUSINESS ADDRESS
PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site
(If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)
ACTUAL DELIVERY in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by: D.R. Form

Printed Name and Signature of Student ______________________________________________ ACTUAL DELIVERY FORM

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-
In Clinics/Homes)
Signature Not
Required)

IMMEDIATE NEWBORN CORD CARE in _______________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province
ICNB Form
Prepared by: IMMEDIATE CARE OF THE
Printed Name and Signature of Student ______________________________________________ NEWBORN FORM

Date Performed Patient’s INITIAL Only Immediate Newborn Cord Care Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Case Number
Time Started Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty, Name and Signature
(not applicable for Birthing
Homes/Lying-In Clinics/Homes) NICU, or Home signature not required)

(STRICTLY NO DESIGNATES)

[These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]