COLLEGE OF NURSING
STUDENT ASSIGNMENT SHEET
CLINICAL INSTRUCTOR (CI): TIME IN OF CI: DATE:
HEAD NURSE (HN) ON DUTY: CI CONTACT NO:
AREA / WARD: SHIFT: LEVEL / SECTION / GROUP:
List of Activities to be Performed:
___ Patient Assessment ___ Admit Patient (Admissions) ___ Assist in Bedside & Dx Procedures ___ Pre-op Preparations
___ Nursing Care Planning ___ Discharge Patient (Discharges) ___ Assist in Suturing and Wound Dressing ___ Gowning
___ Bedside Care ___ Health Teaching, Promotion & Educ. ___ Facilitate lab test UA, FA, etc. ___ Instrument Preparation
___ Focus / DAR Charting ___ Changing of Linens and Blankets ___ OF Feeding, Gastric Lavage & Gavage ___ After Care of Instruments
___ Oral Medications Administration ___ Handwashing ___ Skin Testing ___ Disposal of Sharps
___ Vital Signs Taking and Monitoring ___ Kardexing ___ IFC Insertion ___ Others, specify
___ I and O Recording and Monitoring ___ Nebulization ___ NGT Insertion _______________
___ IVF Priming, Regulation and Monitoring ___ ECG Taking ___ Transcribe Doctor’s Orders ____________________________
_
____________________________
_
Shift / Time Schedule of Activities Nursing Personnel on Duty
(To be filled-out by the HN on duty)
1st HR 1.
2.
2nd HR
3.
3rd HR 4.
4th HR 5.
5th HR 6.
7.
6th HR
8.
7th HR 9.
8th HR 10.
TIME Room /
Name of Student Patient/s Remarks
IN Bed No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Schedule of Pre / Post Conference: TIME OUT:
___________________
Name & Signature of HN
Notes / Reminders of CI to Nursing Personnel-on-Duty:
CLEARANCE FORM AND CLINICAL ROTATION CERTIFICATE
UC-CON-FORM-09_RLE Page 1 of 2
August 24, 2023 Rev.01
COLLEGE OF NURSING
INCLUSIVE DATE/S OF ROTATION:
INSTRUCTOR: GROUP LEADER:
CI CONTACT NO: LEADER CONTACT NO:
LEVEL / SECTION / GROUP: AREA / WARD: SHIFT:
Adverse SOP
Name of Clinical Instructor Tardiness Absence Signature
Events Violations
Name of Students
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
RESPONSIBILITIES:
__ WE have surrendered all materials (check all that apply) which were __ WE have cleared all required forms pertaining to the clinical
entrusted to the clinical group during the rotation: rotation of students in this clinical area / unit:
__ Student Attendance Logbook __ Student Clinical Rotation Evaluation Form (SCEF)
__ Locker Keys __ Clinical Instructor Evaluation of Clinical Rotation Form
__ Audio-Visual Materials (LCD projector, mannequin, etc.) __ Case Slips and Signatures in Logbooks
__ Orientation Manual / Logbook __ Clearance Form and Clinical Rotation Certificate
__ Others, specify: __________________________________ __ Others, specify: __________________________________
Other Comments / Suggestions / Recommendations:
This is to certify that the above information is correct, verified and properly documented.
_________________________________ _________________________________ _________________________________
GROUP LEADER CLINICAL INSTRUCTOR HEAD NURSE / SUPERVISOR
(Name I Signature I Date) (Name I Signature I Date) (Name I Signature I Date)
NOTE: Attach the corresponding Student Assignment Sheet/s, Incident Reports, Evaluation Forms and other pertinent documents that
correspond to this Clinical Rotation. Accomplish this in duplicate form and one (1) copy shall be submitted by the HN/Nurse Supervisor to the
Coordinator for Student Affiliates through the TOCA ASAP.
REMARKS Data Managed by: Received by:
________________________________ __________________________________
UNIT TRAINING OFFICER COORDINATOR FOR STUDENT
(Name I Signature I Date) AFFILIATES
(Name I Signature I Date)
UC-CON-FORM-09_RLE Page 2 of 2
August 24, 2023 Rev.01
