STUDENT PROFILE

Name: _____________________________________________________________________
Course/Year/Section: ________________________________________________________
Address: ___________________________________________________________________
Contact Number:
____________________________________________________________

Father’s Name: _______________________Contact Number:_______________________

Mother’s Name: ______________________ Contact Number:_______________________

Name of Guardian: _______________________Contact Number:____________________

Address: ___________________________________________________________________
 STUDENTS MONITORING SHEET

TEMPERATURE
AM PM Remarks Monitored
Date
Time Time (Symptoms) by:
Temp Temp
Taken Taken
Form No. BSNRLE-DTR01
DAILY TIME RECORD

Name of Student: ___________________________________ Course/Year Level__________

Semester/Academic Year: ______________________________________________________
Name of Clinical Instructor: ____________________________________________________
Subject: __________________________________________ Course Credit: ____________
Required Contact Hours: _______________________________________________________

Uniform &
Date of RLE Time C.I. Time C.I. Area of Paraphernalia
Day
Duty In Initials Out Initials Exposure (complete/
incomplete)
1.
2.
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 39.
40.
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46.
47.
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50.
TOTAL NUMBER OF HOURS COMPLETED

Conforme: ___________________________ Certified by: _________________________

Signature over Printed Name of the Student Signature over Printed Name of the C.I.

For Clinical Instructors Use:

Total No. of RLE hours Attended: ________________________________________
Total No. of Absences: _________________________________________________
Total No. of Tardiness and Under-time: ____________________________________
Lacking No. of hours: __________________________________________________
Remarks: ____________________________________________________________

______________________________________
Clinical Instructor’s Signature over Printed Name
 RELATED LEARNING EXPERIENCE (RLE)/LEARNING JOURNAL
Date of Exposure Area of Exposure
Clinical Instructor Shift
MAJOR ACTIVITIES SPECIFIC ACTIVITIES
A. Pre – conference Time Arrived in the Hospital/Community: _________________
Time Conducted_______ Demerits if any: ______________________________________
Venue:_______________ Narrates the Activities Done:

Time Logged in the Learning Platform_______________

Narrates the activities Done:

B. Endorsement Nurse/Midwife/Barangay Official on Duty: ____________________________

Time Conducted:_______ Narrate the Activities Done:

C. Actual Exposure (Use the following form to help you systematize and concretize your thoughts)
AREA AWARENESS
CONTENT
(What have I learnt?

PROCESS
(How did I learn it?)

REASONS
(Why did I learn it?)

ACADEMIC AND PROFESSIONAL

DEVELOPMENT
(How does the learning experience
contribute to my academic and
professional development?)

PERSONAL DEVELOPMENT
(What does this learning experience
mean to me?)

D. .Post –Conference Narrates the Activities done including the reminders of the Clinical Instructor
Time Conducted:________ prior to departure.
Venue :_______________
Time Out:_____________

Prepared by: Attested :

___________________________________ _________________________________________
Signature over Printed Name of Students Signature over Printed Name of Clinical Instructor
ATTENDANCE MONITORING
Required No. of RLE Hours No. of Tardiness:_________ No. of Absences:____
Total No. of Hours Attended as _________hours Lacking Hours:______
of(Date)______________________
 RELATED LEARNING EXPERIENCE (CLINICAL) STUDENT ‘S
PERFORMANCE EVALUATION TOOL
Area of Exposure: _________________________________ Date:________________________

A. CLINICAL PERFORMANCE ( Skills & Knowledge ) 80 % 5 4 3 2 1

Utilizes effective communication in establishing rapport in the nurse/midwife-patient
1.
interaction/nurse/midwife-patient relationship.
Secures a comprehensive and accurate nursing history of the client reflecting the nursing models as
2.
framework.
3. Documents nursing history completely and accurately in appropriate forms.
4. Performs cephalo-caudal physical examination systematically.
5. Checks and record clients vital signs correctly.
6. Records physical examination’s findings accurately ,laboratory and diagnostic test results.
7. Analyzes the significance of diagnostic test results.
8. Identifies the presenting signs and symptoms conscientiously.
9. Relates accurately the psycho-pathophysiology change of the disease process.
10. Utilizes significant data gathered in determining nursing problems of clients.
11. Identifies nursing problems specific to client’s condition.
12. Prioritizes the identified nursing problems.
13. Utilizes critical thinking in developing plan of care.
14. Integrates therapeutic interventions (medication & treatment) in the plan of care.
15. Thoroughly designs and conducts health teachings for the client and significant others.
16. Completely performs nursing care.
17. Demonstrates flexibility and resourcefulness in performing nursing care.
18. Efficiently administer medications.
19. Observes safety measures and standard precautions appropriately.
20. Accurately monitors intake aand output measures.
21. Collaborates with allied medical services.
22. Documents pertinent data completely and legibly.
23. Evaluates client’s response to nursing care.
24. Modifies care of client based on outcome of evaluation.
B. VALUES / CHARACTER ( Attitude) 20% 5 4 3 2 1
1. Reports on duty promptly at all times.
2. Reports in complete prescribed clinical uniform and paraphernalia.
3. Appears a clean and neat at all times with well-kept hair, well – trimmed nails.
Shows reasonable control of emotion and behavior. Maintains a cheerful and happy disposition in appropriate
4.
situation at all times.
5. Accepts constructive criticism and suggestions graciously.
6. Tactful in handling situations and maintains ethical at all times.
7. Honest and trustworthy.
Shows courtesy and respect, maintains harmonious relationship with clients, hospital management and staff,
8.
clinical instructor and classmates.
Shows enthusiasm to learn on the client’s disease condition and modalities of treatment and modalities of
9.
treatment and care.
10. Complies with requirement promptly at all times.
TOTAL
5 EXCELLENT. Carries out procedure/task efficiently, systematically and independently
4 VERY SATISFACTORY. Carries out procedure/task efficiently, but requires minimal guidance and supervision
3 SATISFACTORY. With moderate guidance and supervision
2 FAIR. Requires close guidance and supervisions
1 POOR. Carries out the procedure/task inefficiently, unsystematically even after close guidance and supervision

REMARKS:
____________________________________________________________________________________________________
________________________________________________________________________________
COMPUTATION:
A. Clinical Performance ______________/120 x 100 = __________ x .80 = __________
B. Vaue / Character ______________/50 x 100 = ___________ x .20 = __________
TOTAL GRADE: ___________ TRANSMUTATED GRADE ( 65% Passing Score ): _________

Prepared by:

_________________________________ ___________________________________
Clinical Instructor Name and Signature of Student
 WRITTEN APPEAL FOR MAKE-UP DUTY

Address: __________________________
Date: _____________________________

MARVIN P. PLATA, MAN, RN, RM

Dean – College of Allied Health Sciences
Marinduque State College
Thru: JOY V. MALILAY, RN, MAN
Assistant Dean/ Chair, Nursing Program

Dear Dean Plata:

I ___________________________________ committed an unavoidable absence on

______________________ due to _____________________________________________,
respectfully seek approval from you good office to make-up the said absence on
_________________________________.

I promise that I will abide by the policies and regulations governing make-up duty and will
follow the rules and guidelines in the RLE Manual during the conduct of the make-up duty.

I and my parent/s fully understood that the salary of the Clinical Instructor who will handle the
make-up duty will be our own costs.

Attached please find are pertinent documents related to this request.

Hoping for your kind consideration.

Respectfully,

__________________________________
Name and Signature of the Student

Conforme:

_________________________________________
Name & Signature of the Parent/Guardian

Recommending Approval:

___________________ ____________________ _____________________

Clinical Instructor Clinical Coordinator Associate Dean - CAHS
Form No.BSNRLE-UA01:

NOTICE OF UNAVOIDABLE ABSENCE

Date : ______________________________________________

To : _______________________________________________
Clinical Instructor

Please be informed that I will be absent on __________________________________

due to the following reasons:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

__________________________________________
Name & Signature of the Student

Conforme:

_________________________________________
Name & Signature of the Parent/Guardian

Noted:

____________________________________________
Name and Signature of the Clinical Instructor

Note: This notice shall be submitted to the Clinical Instructor one (1) day prior to
expected absence. Notification thru cellphone shall be accepted if the circumstance
that brought absence happened on the same day. However student is required to
accomplish this notice upon his/her return.

(Important: This notice will be attached in the “Written Appeal for Make-up Duty”)
Form No.BSNRLE-UT01:

NOTICE OF UNAVOIDABLE TARDINESS

Date : ______________________________________________

To : _______________________________________________
Clinical Instructor

Please be informed that I will be late on __________________________________

due to the following reasons:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

__________________________________________
Name & Signature of the Student

Conforme:

_________________________________________
Name & Signature of the Parent/Guardian

Noted:

____________________________________________
Name and Signature of the Clinical Instructor

Note: This notice shall be submitted to the Clinical Instructor one (1) day prior to
expected absence. Notification thru cellphone shall be accepted if the circumstance
that brought absence happened on the same day. However student is required to
accomplish this notice upon his/her return.

(Important: This notice will be attached in the “Written Appeal for Make-up Duty”)
Form No. BSNRLE-ED01:

REQUEST FOR EARLY DEPARTURE FROM CLINICAL DUTY

Date : ______________________________________________

To : _______________________________________________
Clinical Instructor

May I be allowed to go home early this __________________________________ due

to the following reasons:
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

__________________________________________
Name & Signature of the Student

Conforme:

_________________________________________
Name & Signature of the Parent/Guardian

Noted:

____________________________________________
Name and Signature of the Clinical Instructor

Note: This notice shall be submitted to the Clinical Instructor one (1) day prior to
expected absence. Notification thru cellphone shall be accepted if the circumstance
that brought absence happened on the same day. However student is required to
accomplish this notice upon his/her return.

(Important: This notice will be attached in the “Written Appeal for Make-up Duty”)
Form No. BSNRLE-IR01

SPECIAL INCIDENT REPORT FORM

Name of Student:_____________________________________________________
Course/Year/Level: _______________________ Date:___________________
Area of Assignment: _____________________ _ Shift:___________________

Name of patient: _____________________________ Age:____________________

Physician:___________________________________________________________
Diagnosis:___________________________________________________________
Nature of incident:_____________________________________________________
Time and date: _______________________________________________________
Person/s notified: ______________________

DETAILED EXPLANATION OF THE STUDENT:

___________________________
Name &Signature of the Student

REMARKS OF THE PERSON NOTIFIED:

__________________________
Nurse on Duty

__________________________
Clinical Instructor

REMARKS OF THE CLINICAL COORDINATOR:

__________________________
Clinical Coordinator