College of Nursing Osmea Boulevard Cebu City 6000 254 4837 / cnucollegeofnursing@live.com.

.ph Level IV RE-ACCREDITED STATUS, AACCUP Surgical Scrub in Vicente Sotto Memorial Medical Center Prepared by:
Printed Name with Signature of Student: _________________________________

Cebu Normal University

ODC Form 2A O.R. SCRUB FORM MAJOR

Date Performed and Time Started

Patients Initials (only) Case Number

Surgical Procedure Performed

O.R. Nurses on Duty (Name and Signature)

Supervised by Clinical instructor Name and Signature

Supervised by:

Jillian A. Bejoc (Print Name and Signature) OR Coordinator PRC I.D. No.: 0264090 Valid Until: February 7, 2012 Date Document is signed: __________ Time: _______ Highest Nursing Degree Earned: MSN, RN PNA number: 16239 Valid Until: Life member

Noted by: Julius C. Dao (Print Name and Signature) Clinical Coordinator PRC I.D. No. 0155912 Valid Until: July 1, 2012 Date Document is signed: ___________ Time: ____ Highest Nursing Degree Earned: MAEd, MPHC, RN PNA number: 058602 Valid Until: October 31, 2011

Approved by: Daisy R. Palompon (Print Name and Signature) Dean PRC I.D. No. 0253183 Valid Until: July 3, 2011 Date Document is signed:________ Time:_____ Highest Nursing Degree Earned: Ph.D, MAN, RN PNA number: 18183 Valid Until: Life member

College of Nursing Osmea Boulevard Cebu City 6000 254 4837 / cnucollegeofnursing@live.com.ph Level IV RE-ACCREDITED STATUS, AACCUP Surgical Scrub in Cebu City Memorial Medical Center Prepared by:
Printed Name with Signature of Student: _________________________________

Cebu Normal University

ODC Form 2A O.R. SCRUB FORM MAJOR

Date Performed and Time Started

Patients Initials (only) Case Number

Surgical Procedure Performed

O.R. Nurses on Duty (Name and Signature)

Supervised by Clinical instructor Name and Signature

Supervised by:

Jillian A. Bejoc (Print Name and Signature) OR Coordinator PRC I.D. No.: 0264090 Valid Until: February 7, 2012 Date Document is signed: __________ Time: _______ Highest Nursing Degree Earned: MSN, RN PNA number: 16239 Valid Until: Life member

Noted by: Julius C. Dao (Print Name and Signature) Clinical Coordinator PRC I.D. No. 0155912 Valid Until: July 1, 2012 Date Document is signed: ___________ Time: ____ Highest Nursing Degree Earned: MAEd, MPHC, RN PNA number: 058602 Valid Until: October 31, 2011

Approved by: Daisy R. Palompon (Print Name and Signature) Dean PRC I.D. No. 0253183 Valid Until: July 3, 2011 Date Document is signed:________ Time:_____ Highest Nursing Degree Earned: Ph.D, MAN, RN PNA number: 18183 Valid Until: Life member

College of Nursing Osmea Boulevard Cebu City 6000 254 4837 / cnucollegeofnursing@live.com.ph Level IV RE-ACCREDITED STATUS, AACCUP Surgical Scrub in Cebu Puericulture Center and Maternity House Incorporated Prepared by:
Printed Name with Signature of Student: _________________________________

Cebu Normal University

ODC Form 2A O.R. SCRUB FORM MAJOR

Date Performed and Time Started

Patients Initials (only) Case Number

Surgical Procedure Performed

O.R. Nurses on Duty (Name and Signature)

Supervised by Clinical instructor Name and Signature

Supervised by:

Jillian A. Bejoc (Print Name and Signature) OR Coordinator PRC I.D. No.: 0264090 Valid Until: February 7, 2012 Date Document is signed: __________ Time: _______ Highest Nursing Degree Earned: MSN, RN PNA number: 16239 Valid Until: Life member

Noted by: Julius C. Dao (Print Name and Signature) Clinical Coordinator PRC I.D. No. 0155912 Valid Until: July 1, 2012 Date Document is signed: ___________ Time: ____ Highest Nursing Degree Earned: MAEd, MPHC, RN PNA number: 058602 Valid Until: October 31, 2011

Approved by: Daisy R. Palompon (Print Name and Signature) Dean PRC I.D. No. 0253183 Valid Until: July 3, 2011 Date Document is signed:________ Time:_____ Highest Nursing Degree Earned: Ph.D, MAN, RN PNA number: 18183 Valid Until: Life member

College of Nursing Osmea Boulevard Cebu City 6000 254 4837 / cnucollegeofnursing@live.com.ph Level IV RE-ACCREDITED STATUS, AACCUP Circulating Case in Cebu City Memorial Medical Center Prepared by:
Printed Name with Signature of Student: _________________________________

Cebu Normal University

ODC Form 2A O.R. SCRUB FORM MAJOR CIRCU

Date Performed and Time Started

Patients Initials (only) Case Number

Surgical Procedure Performed

O.R. Nurses on Duty (Name and Signature)

Supervised by Clinical instructor Name and Signature

Supervised by:

Jillian A. Bejoc (Print Name and Signature) OR Coordinator PRC I.D. No.: 0264090 Valid Until: February 7, 2012 Date Document is signed: __________ Time: _______ Highest Nursing Degree Earned: MSN, RN PNA number: 16239 Valid Until: Life member

Noted by: Julius C. Dao (Print Name and Signature) Clinical Coordinator PRC I.D. No. 0155912 Valid Until: July 1, 2012 Date Document is signed: ___________ Time: ____ Highest Nursing Degree Earned: MAEd, MPHC, RN PNA number: 058602 Valid Until: October 31, 2011

Approved by: Daisy R. Palompon (Print Name and Signature) Dean PRC I.D. No. 0253183 Valid Until: July 3, 2011 Date Document is signed:________ Time:_____ Highest Nursing Degree Earned: Ph.D, MAN, RN PNA number: 18183 Valid Until: Life member

College of Nursing Osmea Boulevard Cebu City 6000 254 4837 / cnucollegeofnursing@live.com.ph Level IV RE-ACCREDITED STATUS, AACCUP Circulating Case in Vicente Sotto Memorial Medical Center Prepared by:
Printed Name with Signature of Student: _________________________________

Cebu Normal University

ODC Form 2A O.R. SCRUB FORM MAJOR CIRCU

Date Performed and Time Started

Patients Initials (only) Case Number

Surgical Procedure Performed

O.R. Nurses on Duty (Name and Signature)

Supervised by Clinical instructor Name and Signature

Supervised by:

Jillian A. Bejoc (Print Name and Signature) OR Coordinator PRC I.D. No.: 0264090 Valid Until: February 7, 2012 Date Document is signed: __________ Time: _______ Highest Nursing Degree Earned: MSN, RN PNA number: 16239 Valid Until: Life member

Noted by: Julius C. Dao (Print Name and Signature) Clinical Coordinator PRC I.D. No. 0155912 Valid Until: July 1, 2012 Date Document is signed: ___________ Time: ____ Highest Nursing Degree Earned: MAEd, MPHC, RN PNA number: 058602 Valid Until: October 31, 2011

Approved by: Daisy R. Palompon (Print Name and Signature) Dean PRC I.D. No. 0253183 Valid Until: July 3, 2011 Date Document is signed:________ Time:_____ Highest Nursing Degree Earned: Ph.D, MAN, RN PNA number: 18183 Valid Until: Life member

College of Nursing Osmea Boulevard Cebu City 6000 254 4837 / cnucollegeofnursing@live.com.ph Level IV RE-ACCREDITED STATUS, AACCUP Circulating Case in Cebu Puericulture Center and Maternity House Incorporated Prepared by:
Printed Name with Signature of Student: _________________________________

Cebu Normal University

ODC Form 2A O.R. SCRUB FORM MAJOR CIRCU

Date Performed and Time Started

Patients Initials (only) Case Number

Surgical Procedure Performed

O.R. Nurses on Duty (Name and Signature)

Supervised by Clinical instructor Name and Signature

Supervised by:

Jillian A. Bejoc (Print Name and Signature) OR Coordinator PRC I.D. No.: 0264090 Valid Until: February 7, 2012 Date Document is signed: __________ Time: _______ Highest Nursing Degree Earned: MSN, RN PNA number: 16239 Valid Until: Life member

Noted by: Julius C. Dao (Print Name and Signature) Clinical Coordinator PRC I.D. No. 0155912 Valid Until: July 1, 2012 Date Document is signed: ___________ Time: ____ Highest Nursing Degree Earned: MAEd, MPHC, RN PNA number: 058602 Valid Until: October 31, 2011

Approved by: Daisy R. Palompon (Print Name and Signature) Dean PRC I.D. No. 0253183 Valid Until: July 3, 2011 Date Document is signed:________ Time:_____ Highest Nursing Degree Earned: Ph.D, MAN, RN PNA number: 18183 Valid Until: Life member