Our Lady of Fatima University

College of Physical Therapy

Clinical Internship Program

Daily Time Record

NAME : Kimberly Ann A. Pagalilauan

MONTH/YEAR : JANUARY 2020
AFFILIATION CENTER : Fatima Eye and Rehab Center
OFFICIAL DUTY : 8:00 AM-5:00 PM

DATE MORNING AFTERNOON

IN OUT IN OUT
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Numbers of days absent: __________________

Excused : __________________
Unexcused : __________________
Freq. of Tardiness : __________________
Total No. of Make-ups : __________________

Merits: __________________
Reason: __________________

Demerits: __________________
Reason: __________________

Clinical Supervisor Remarks:

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I hereby certify that above records are true and correct
report of my duty hours which was made daily at the time
of my arrival and departure from the clinic/center.

Kimberly Ann A. Pagalilauan Kristina Piol, PTRP

OLFU AC PT Intern ‘19-20 Clinical Supervisor
(SIGNATURE OVER PRINTED NAME) (SIGNATURE OVER PRINTED NAME)

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 Ma. Mikaela G. Tagal II
Internship Coordinator
(SIGNATURE OVER PRINTED NAME)