O.R.

Form 1B
O.R. CIRCULATING FORM MAJOR

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
SURGICAL CIRCULATING in
Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student: ________________________________
Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: MA. LOURDES M. WEE SIT, R.N., M.N.,

Clinical Coordinator, PRC I.D. No. 0102273 Valid Until:

Approved by: NURSIA M. BARJOSE,RN,MN,DSN

Dean, PRC I.D. No. 0138378 Valid Until: January 29, 2019

Date document is signed:

Please specify Highest Nursing Degree Earned:

Date document is signed:

Time:
O.R. Form 1B
Specify Highest Nursing Degree Earned: Doctor in Science of Nursing

July 18, 2018

Time:
Master in Nursing

WESTERN MINDANAO STATE UNIVERSITY

O.R. SCRUB FORM MAJOR

Normal Road, Baliwasan, Zamboanga City, Philippines

Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
SURGICAL SRUB in
Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student: ________________________________
Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

Noted by: MA. LOURDES M. WEE SIT, RN, MN

Clinical Coordinator, PRC I.D. No. 0102273 Valid Until:
Date document is signed:
Please specify Highest Nursing Degree Earned:

PROCEDURE PERFORMED

July 18, 2018

Time:
Master in Nursing

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Approved by: NURSIA M. BARJOSE,RN,MN,DSN

Dean, PRC I.D. No. 0138378 Valid Until: January 29, 2019
Date document is signed:
Time:
Specify Highest Nursing Degree Earned: Doctor in Science of Nursing