University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: cn@post.upm.edu.ph
Website: http://cn.upm.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

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






(STRICTLY NO DESIGNATES)
[These Forms must be printed at the back of the 1
st
page of the Competency-Based Performance Evaluation Checklist prescribed by the BON]




Noted by: ARNOLD B. PERALTA, BSN, MAN, MHPeD
(Print Name and Signature)
Clinical Coordinator, N-105
PRC ID NO. __________ Valid Until ____________
Date Signed: _________________ Time: ________

Noted by:
(Print Name and Signature)
Chief Nurse
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

Approved by: LOURDES MARIE S. TEJERO, RN, MAN, PhD
(Print Name and Signature)
Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

O.R. Form 1A
O.R. SCRUB FORM
Major

University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: cn@post.upm.edu.ph
Website: http://cn.upm.edu.ph


SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

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






(STRICTLY NO DESIGNATES)
[These Forms must be printed at the back of the 1
st
page of the Competency-Based Performance Evaluation Checklist prescribed by the BON]
O.R. Form 1B
O.R. CIRCULATING
FORM
University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: cn@post.upm.edu.ph
Website: http://cn.upm.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

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







Noted by: ARNOLD B. PERALTA, BSN, MAN, MHPeD
(Print Name and Signature)
Clinical Coordinator, N-105
PRC ID NO. __________ Valid Until ___________
Date Signed: _______________ Time: ______

Noted by:
(Print Name and Signature)
Chief Nurse, Dr. Jose Fabella Memorial Hospital
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

Approved by: LOURDES MARIE S. TEJERO, RN, MAN, PhD
(Print Name and Signature)
Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________


(STRICTLY NO DESIGNATES)

ODC Form 2A
O.R. SCRUB FORM
Major