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OR Scrub Forms

The document consists of two forms from the University of Iloilo related to surgical procedures: ODC Form 2A for surgical scrubs and ODC Form 2B for circulating roles. Each form requires details such as the student's name, patient initials, surgical procedure, and signatures from the O.R. nurse and clinical instructor. Additionally, it includes sections for approval by clinical coordinators and deans, along with educational qualifications.

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jecirryfatagani19
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17 views2 pages

OR Scrub Forms

The document consists of two forms from the University of Iloilo related to surgical procedures: ODC Form 2A for surgical scrubs and ODC Form 2B for circulating roles. Each form requires details such as the student's name, patient initials, surgical procedure, and signatures from the O.R. nurse and clinical instructor. Additionally, it includes sections for approval by clinical coordinators and deans, along with educational qualifications.

Uploaded by

jecirryfatagani19
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ODC Form 2A

UNIVERSITY OF ILOILO
O.R. SCRUB FORM
Rizal St., Iloilo City MAJOR
Tel. No. (033) 338-1071 loc. 146

SURGICAL SCRUB in _____________________________________________________________________________________________


Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

Noted by : _____________________________________________________________ Approved by:__________________________________________________________


(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean, PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time___________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________
ODC Form 2B
UNIVERSITY OF ILOILO O.R. CIRCULATING FORM
Rizal St., Iloilo City
Tel. No. (033) 338-1071 loc. 146

SURGICAL SCRUB in _____________________________________________________________________________________________


Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Date Performed Patient’s Initial Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

Noted by : _____________________________________________________________ Approved by:__________________________________________________________


(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC ID No.__________________Valid Until__________________ Dean, PRC I.D. No._______________________Valid Until_______________________
Date document is signed________________________Time______________________ Date document is signed__________________Time__________________________
Please specify Highest Degree Earned________________________________________ Highest Nursing Degree Earned____________________________________________

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