Prc bon memorandum-order-no-2 b-odc form-series-of-2009

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Prc bon memorandum-order-no-2 b-odc form-series-of-2009

  1. 1. ODC Form 2A O.R. SCRUB FORM SCHOOL Major LOGO NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) SURGICAL SCRUB in ________________________________________________________________________ Hospital, Municipality/City/ProvincePrepared by:Printed Name with Signature of Student ______________________________________________ Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY and SURGICAL PROCEDURE (Name AND Signature) Clinical Instructor Time Started Case Number Name and Signature PERFORMEDNoted by: _______________________________________________ Approved by: ___________________________________________________(Print Name and Signature) (Print Name and Signature)Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________ (STRICTLY NO DESIGNATES)
  2. 2. ODC Form 2B O.R. MINOR FORM SCHOOL LOGO NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) SURGICAL SCRUB in ________________________________________________________________________ Hospital, Municipality/City/ProvincePrepared by:Printed Name and Signature of Student ______________________________________________ Date Performed Patient’s INITIALS Only O.R. Nurse On Duty SUPERVISED BY and SURGICAL PROCEDURE (Name and Signature) Clinical Instructor Time Started Case Number Name and Signature PERFORMEDNoted by: _______________________________________________ Approved by: ___________________________________________________(Print Name and Signature) (Print Name and Signature)Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________ (STRICTLY NO DESIGNATES)
  3. 3. ODC Form 1A SCHOOL ACTUAL DELIVERY FORM LOGO NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) ACTUAL DELIVERY in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/ProvincePrepared by:Printed Name and Signature of Student ______________________________________________ Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty SUPERVISED BY and PERFORMED (Name and Signature) Clinical Instructor Time Started Case Number (If Midwife on Duty, Name and Signature (not applicable for Birthing/Lying- In Clinics/Homes) Signature Not Required)Noted by: _______________________________________________ Approved by: ___________________________________________________(Print Name and Signature) (Print Name and Signature)Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________ (STRICTLY NO DESIGNATES)
  4. 4. SCHOOL ODC Form 1B LOGO ASSISTED DELIVERY FORM NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) ACTUAL DELIVERY in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/ProvincePrepared by:Printed Name and Signature of Student ______________________________________________ Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty SUPERVISED BY and PERFORMED (Name and Signature) Clinical Instructor Time Started Case Number (If Midwife on Duty, Name and Signature (not applicable for Birthing/Lying- In Clinics/Homes) Signature Not ASSISTED DELIVERY Required)Noted by: _______________________________________________ Approved by: ___________________________________________________(Print Name and Signature) (Print Name and Signature)Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________ (STRICTLY NO DESIGNATES)
  5. 5. SCHOOL ODC Form 1C CORD CARE FORM LOGO NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/ProvincePrepared by:Printed Name and Signature of Student ______________________________________________ Date Performed Patient’s INITIAL Only Immediate Newborn Cord Care Nurse On Duty SUPERVISED BY and PERFORMED (Name and Signature) Clinical Instructor Case Number Time Started Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty, Name and Signature (not applicable for Birthing Homes/Lying-In Clinics/Homes) NICU, or Home signature not required)Noted by: _______________________________________________ Approved by: ___________________________________________________(Print Name and Signature) (Print Name and Signature)Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Dean, PRC I.D. No. ____________________ Valid Until __________________________Date document is signed: _________________________ Time __________________ Date document is signed: ______________________ Time: _______________________Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned: ______________________________________ (STRICTLY NO DESIGNATES)

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