DE LA SALLE LIPA ODC Form 2A
O.R. SCRUB FORM
1962 Pres. J.P. Laurel National Highway, Lipa City 4217, Batangas, Philippines Major
Trunkline (+63 43) 756-55-55 ∙ 756-24-91 local 270 ∙ Fax (+63 43) 756-31-17
www.dlsl.edu.ph
Date School/Program was recognized: April 12, 2007 Number: 035 Year: 2007
SURGICAL SCRUB in ___________________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _____________________________
Patient’s INITIALS
Date Performed (only) SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name AND Signature)
Time Started Case Number Name and Signature
Noted by: __________________________________ Noted by: __________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator Dean
PRC ID No.: _______ Valid Until: ___________ PRC ID No.: _______ Valid Until: ___________
Date document is signed: _____________ Time: _______ Date document is signed: _____________ Time: _______
Please specify Highest Nursing Degree Earned: ________ Please specify Highest Nursing Degree Earned: ________
DE LA SALLE LIPA ODC Form 2B
1962 Pres. J.P. Laurel National Highway, Lipa City 4217, Batangas, Philippines
O.R. SCRUB FORM
Trunkline (+63 43) 756-55-55 ∙ 756-24-91 local 270 ∙ Fax (+63 43) 756-31-17 Minor
www.dlsl.edu.ph
Date School/Program was recognized: April 12, 2007 Number: 035 Year: 2007
SURGICAL SCRUB in __________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _________________________________
Patient’s INITIALS
Date Performed (only) SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name AND Signature)
Time Started Case Number Name and Signature
Noted by: __________________________________ Noted by: __________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator Dean
PRC ID No.: _______ Valid Until: ___________ PRC ID No.: _______ Valid Until: ___________
Date document is signed: _____________ Time: _______ Date document is signed: _____________ Time: _______
Please specify Highest Nursing Degree Earned: ________ Please specify Highest Nursing Degree Earned: ________
ODC Form 2C
DE LA SALLE LIPA
O.R. SCRUB FORM
Circulating
1962 Pres. J.P. Laurel National Highway, Lipa City 4217, Batangas, Philippines
Trunkline (+63 43) 756-55-55 ∙ 756-24-91 local 270 ∙ Fax (+63 43) 756-31-17
www.dlsl.edu.ph
Date School/Program was recognized: April 12, 2007 Number: 035 Year: 2007
SURGICAL SCRUB in ______________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ________________________________
Patient’s INITIALS
Date Performed (only) SURGICAL PROCEDURE SUPERVISED BY
O.R. Nurse On Duty
and PERFORMED / Clinical Instructor
(Name AND Signature)
Time Started Case Number Circulating Name and Signature
Noted by: __________________________________ Noted by: __________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator Dean
PRC ID No.: _______ Valid Until: ___________ PRC ID No.: _______ Valid Until: ___________
Date document is signed: _____________ Time: _______ Date document is signed: _____________ Time: _______
Please specify Highest Nursing Degree Earned: ________ Please specify Highest Nursing Degree Earned: ________
DE LA SALLE LIPA ODC Form 1A
ACTUAL DELIVERY
1962 Pres. J.P. Laurel National Highway, Lipa City 4217, Batangas, Philippines FORM
Trunkline (+63 43) 756-55-55 ∙ 756-24-91 local 270 ∙ Fax (+63 43) 756-31-17
www.dlsl.edu.ph
Date School/Program was recognized: April 12, 2007 Number: 035 Year: 2007
ACTUAL DELIVERY in ___________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ____________________________
Patient’s INITIALS (only) O.R. Nurse On Duty
Date Performed (Name AND Signature) SUPERVISED BY
and Case Number PROCEDURE PERFORMED (If Midwife on Duty, Clinical Instructor
Time Started (not applicable for Signature Not Name and Signature
Birthing/Lying-in Clinics/Homes) Required)
Noted by: __________________________________ Noted by: __________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator Dean
PRC ID No.: _______ Valid Until: ___________ PRC ID No.: _______ Valid Until: ___________
Date document is signed: _____________ Time: _______ Date document is signed: _____________ Time: _______
Please specify Highest Nursing Degree Earned: ________ Please specify Highest Nursing Degree Earned: ________
DE LA SALLE LIPA ODC Form 1B
ASSISTED DELIVERY
1962 Pres. J.P. Laurel National Highway, Lipa City 4217, Batangas, Philippines FORM
Trunkline (+63 43) 756-55-55 ∙ 756-24-91 local 270 ∙ Fax (+63 43) 756-31-17
www.dlsl.edu.ph
Date School/Program was recognized: April 12, 2007 Number: 035 Year: 2007
ACTUAL DELIVERY in ______________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ________________________
Patient’s INITIALS (only) O.R. Nurse On Duty
Date Performed (Name AND Signature) SUPERVISED BY
PROCEDURE PERFORMED
and Case Number (If Midwife on Duty, Clinical Instructor
ASSISTED DELIVERY
Time Started (not applicable for Signature Not Name and Signature
Birthing/Lying-in Clinics/Homes) Required)
Noted by: __________________________________ Noted by: __________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator Dean
PRC ID No.: _______ Valid Until: ___________ PRC ID No.: _______ Valid Until: ___________
Date document is signed: _____________ Time: _______ Date document is signed: _____________ Time: _______
Please specify Highest Nursing Degree Earned: ________ Please specify Highest Nursing Degree Earned: ________
DE LA SALLE LIPA ODC Form 1C
CORD CARE FORM
1962 Pres. J.P. Laurel National Highway, Lipa City 4217, Batangas, Philippines
Trunkline (+63 43) 756-55-55 ∙ 756-24-91 local 270 ∙ Fax (+63 43) 756-31-17
www.dlsl.edu.ph
Date School/Program was recognized: April 12, 2007 Number: 035 Year: 2007
IMMEDIATE NEWBORN CORD CARE in ______________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _____________________________
Patient’s INITIALS O.R. Nurse On Duty
(only) Immediate Newborn Cord Care (Name AND
Date Performed SUPERVISED BY
Case Number PERFORMED Signature)
and Clinical Instructor
(not applicable for Indicate where performed e.g. D.R., (If Midwife on Duty,
Time Started Name and Signature
Birthing/Lying-in Nursery, NICU, or Home Signature Not
Clinics/Homes) Required)
Noted by: __________________________________ Noted by: __________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator Dean
PRC ID No.: _______ Valid Until: ___________ PRC ID No.: _______ Valid Until: ___________
Date document is signed: _____________ Time: _______ Date document is signed: _____________ Time: _______
Please specify Highest Nursing Degree Earned: ________ Please specify Highest Nursing Degree Earned: ________
