Santiago City, Isabela, Philippines

Tel/Fax: (078) 682-8454

www.northeasterncollege.edu.ph

CHED Recognition No. #23

SURGICAL SCRUB in ____________________________________

Prepared by: ODC FORM 2B

Printed Name and Signature of Student: _________________________ O.R. SCRUB FORM

DATE PERFORMED Patient’s Initial Only Supervised By Clinical

O.R. Nurse on Duty
And SURGICAL Procedure Performed Instructor
Case Number (Name and Signature)
Time Started (Name and Signature)

Noted By: Approved By:

__________________________________ __________________________________
Signature Over Printed Name Signature Over Printed Name

Clinical Coordinator, PRC ID No.: ___________ Valid until: ______________ Dean, PRC ID No.: _________________Valid Until: _________________
Date Document is Signed __________________Time __________________ Date Document is Signed __________________Time _______________
Please specify Highest Nursing Degree Earned: ______________________ Please specify Highest Nursing Degree Earned: ____________________

(STRICTLY NO DESIGNATES)
 Santiago City, Isabela, Philippines
Tel/Fax: (078) 682-8454
www.northeasterncollege.edu.ph

CHED Recognition No. #23

ACTUAL DELIVERY in ____________________________________

Prepared by: ODC FORM 2B

Printed Name and Signature of Student: _________________________ ACTUAL DELIVERY FORM

DATE PERFORMED Patient’s Initial Only Supervised By

PROCEDURE PERFORMED O.R. Nurse on Duty
And Clinical Instructor
Case Number ACTUAL DELIVERY (Name and Signature)
Time Started (Name and Signature)

Noted By: Approved By:

__________________________________ __________________________________
Signature Over Printed Name Signature Over Printed Name

Clinical Coordinator, PRC ID No.: ___________ Valid until: ______________ Dean, PRC ID No.: _________________Valid Until: _________________
Date Document is Signed __________________Time __________________ Date Document is Signed __________________Time _______________
Please specify Highest Nursing Degree Earned: ______________________ Please specify Highest Nursing Degree Earned: ____________________

(STRICTLY NO DESIGNATES)
 Santiago City, Isabela, Philippines
Tel/Fax: (078) 682-8454
www.northeasterncollege.edu.ph

CHED Recognition No. #23

ASSISTED DELIVERY in ____________________________________

Prepared by: ODC FORM 2B

Printed Name and Signature of Student: _________________________ ASSISTED DELIVERY FORM

DATE PERFORMED Patient’s Initial Only Supervised By

PROCEDURE PERFORMED O.R. Nurse on Duty
And Clinical Instructor
Case Number ACTUAL DELIVERY (Name and Signature)
Time Started (Name and Signature)

Noted By: Approved By:

__________________________________ __________________________________
Signature Over Printed Name Signature Over Printed Name

Clinical Coordinator, PRC ID No.: ___________ Valid until: ______________ Dean, PRC ID No.: _________________Valid Until: _________________
Date Document is Signed __________________Time __________________ Date Document is Signed __________________Time _______________
Please specify Highest Nursing Degree Earned: ______________________ Please specify Highest Nursing Degree Earned: ____________________

(STRICTLY NO DESIGNATES)
 Santiago City, Isabela, Philippines
Tel/Fax: (078) 682-8454
www.northeasterncollege.edu.ph

CHED Recognition No. #23

CIRCULATING in ____________________________________

Prepared by: ODC FORM 2B

Printed Name and Signature of Student: _________________________ CIRCULATING FORM

DATE PERFORMED Patient’s Initial Only Supervised By

O.R. Nurse on Duty
And SURGICAL Procedure Performed Clinical Instructor
Case Number (Name and Signature)
Time Started (Name and Signature)

Noted By: Approved By:

__________________________________ __________________________________
Signature Over Printed Name Signature Over Printed Name

Clinical Coordinator, PRC ID No.: ___________ Valid until: ______________ Dean, PRC ID No.: _________________Valid Until: _________________
Date Document is Signed __________________Time __________________ Date Document is Signed __________________Time _______________
Please specify Highest Nursing Degree Earned: ______________________ Please specify Highest Nursing Degree Earned: ____________________

(STRICTLY NO DESIGNATES)
 Santiago City, Isabela, Philippines
Tel/Fax: (078) 682-8454
www.northeasterncollege.edu.ph

CHED Recognition No. #23

IMMEDIATE NEWBORN CORD CARE in ____________________________________

Prepared by: ODC FORM 2B

Printed Name and Signature of Student: _________________________ IMMEDIATE NEW BORN CARE FORM

DATE PERFORMED Patient’s Initial Only IMMEDIATE NEW BORN CORD CARE O.R. Nurse on Duty Supervised By
And PERFORMED Indicate where performed e.g (Name and Signature) Clinical Instructor
Time Started Case Number D.R. Nursery, NICU or Home If Midwife on Duty, Signature not required (Name and Signature)

Noted By: Approved By:

__________________________________ __________________________________
Signature Over Printed Name Signature Over Printed Name

Clinical Coordinator, PRC ID No.: ___________ Valid until: ______________ Dean, PRC ID No.: _________________Valid Until: _________________
Date Document is Signed __________________Time __________________ Date Document is Signed __________________Time _______________
Please specify Highest Nursing Degree Earned: ______________________ Please specify Highest Nursing Degree Earned: ____________________

(STRICTLY NO DESIGNATES)