UNIVERSITY OF CEBU at PARDO and TALISAY, INC.

Bulacao, Cebu City

College of Nursing
TEL. NO. 272-8475 / 272-2985

ACTUAL DELIVERY in ______________________________________________ D.R. FORM

ACTUAL DELIVERY FORM

Prepared by: ____________________________________
( Signature of Student over Printed Name)

SUPERVISED BY
Patient’s Initial only D.R. Nurse On Duty
Date Performed Clinical Instructor
and Time PROCEDURE PERFORMED
(Complete Name and
Started (Complete Name and
Case Number Signature)
Signature)

PRC License #:_________

Expiration Date: ________

Noted by: ____________________________________________ Approved by: ________________________________________

Clinical Coordinator Dean

PRC I.D. No. _________ Valid Until ______________ PRC I.D. No. _______________ Valid Until ______________

Date document is signed :__________________ Time: __________ Date document is signed:________________ Time :___________

Highest Nursing Degree Earned : ___________________________ Highest Nursing Degree Earned: _________________________
 UNIVERSITY OF CEBU at PARDO and TALISAY, INC.
Bulacao, Cebu City
College of Nursing
TEL. NO. 272-8475 / 272-2985

ASSISTED DELIVERY in _____________________________________________________

D.R. FORM

Prepared by: ____________________________________ ASSISTED DELIVERY FORM

( Signature of Student over Printed Name)

SUPERVISED BY
Patient’s Initial only D.R. Nurse On Duty
Date Performed Clinical Instructor
and Time PROCEDURE PERFORMED
(Complete Name and
Started (Complete Name and
Case Number Signature)
Signature)

PRC License #:_________

Expiration Date: ________

Noted by: _____________________________________________ Approved by: ________________________________________

Clinical Coordinator Dean

PRC I.D. No. ______ Valid Until _________________ PRC I.D. No. _______________ Valid Until ______________

Date document is signed :__________________ Time: __________ Date document is signed:________________ Time :___________

Highest Nursing Degree Earned : ___________________________ Highest Nursing Degree Earned: _________________________
 UNIVERSITY OF CEBU at PARDO and TALISAY, INC.
Bulacao, Cebu City
College of Nursing
TEL. NO. 272-8475 / 272-2985

D.R. FORM
IMMEDIATE NEWBORN CORD CARE in _______________________________________________
IMMEDIATE NEWBORN
Prepared by: ____________________________________ CORD CARE FORM
( Signature of Student over Printed Name)

SUPERVISED BY
Patient’s Initial only Immediate Newborn Cord Care D.R. Nurse On Duty
Date Performed Clinical Instructor
PERFORMED
and Time
Indicate where performed e.g. D.R., Nursery, NICU, (Complete Name and
Started (Complete Name and
Case Number or Home Signature)
Signature)

PRC License #:_________

Expiration Date: ________

Noted by: _____________________________________________ Approved by: ________________________________________

Clinical Coordinator Dean

PRC I.D. No. ______ Valid Until _________________ PRC I.D. No. _______________ Valid Until ______________

Date document is signed :__________________ Time: __________ Date document is signed:________________ Time :___________

Highest Nursing Degree Earned : ___________________________ Highest Nursing Degree Earned: _________________________
 UNIVERSITY OF CEBU at PARDO and TALISAY, INC.
Bulacao, Cebu City
College of Nursing
TEL. NO. 272-8475 / 272-2985

SURGICAL SCRUB (Major) in ___________________________________________

O.R. FORM

Prepared by: ____________________________________ OR MAJOR SCRUB FORM

( Signature of Student over Printed Name)

Patient’s Initial only SUPERVISED BY

O.R. Nurse On Duty
Date Performed Clinical Instructor
and SURGICAL PROCEDURE PERFORMED
(Complete Name and
Time Started (Complete Name and
Case Number Signature)
Signature)

PRC License #:_________

Expiration Date: ________

Noted by: _____________________________________________ Approved by: ________________________________________

Clinical Coordinator Dean

PRC I.D. No. ______ Valid Until _________________ PRC I.D. No. _______________ Valid Until ______________

Date document is signed :__________________ Time: __________ Date document is signed:________________ Time :___________

Highest Nursing Degree Earned : ___________________________ Highest Nursing Degree Earned: _________________________
 UNIVERSITY OF CEBU at PARDO and TALISAY, INC.
Bulacao, Cebu City
College of Nursing
TEL. NO. 272-8475 / 272-2985

SURGICAL SCRUB (Minor) in _____________________________________________________

O.R. FORM
Prepared by: _________________________________________
OR MINOR SCRUB FORM
( Signature of Student over Printed Name)

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

PRC License #:_________

Expiration Date: ________

Noted by: _____________________________________________ Approved by: ________________________________________

Clinical Coordinator Dean

PRC I.D. No. ______ Valid Until _________________ PRC I.D. No. _______________ Valid Until ______________

Date document is signed :__________________ Time: __________ Date document is signed:________________ Time :___________

Highest Nursing Degree Earned : ___________________________ Highest Nursing Degree Earned: _________________________
 UNIVERSITY OF CEBU at PARDO and TALISAY, INC.
Bulacao, Cebu City
College of Nursing
TEL. NO. 272-8475 / 272-2985

SURGICAL SCRUB (Circulating) in __________________________________________________________

O.R. FORM
Prepared by: ____________________________________
( Signature of Student over Printed Name) CIRCULATING FORM

Patient’s INITIAL only SUPERVISED BY

O.R. Nurse On Duty
Date Performed Clinical Instructor
SURGICAL PROCEDURE
and
Case Number PERFORMED (Complete Name and
Time Started (Complete Name and
Signature)
Signature)

PRC License#:_________

Expiration Date: _______

Noted by: _____________________________________________ Approved by: ________________________________________

Clinical Coordinator Dean

PRC I.D. No. ______ Valid Until _________________ PRC I.D. No. _______________ Valid Until ______________

Date document is signed :__________________ Time: __________ Date document is signed:________________ Time :___________

Highest Nursing Degree Earned : ___________________________ Highest Nursing Degree Earned: _________________________