ODC Form 2A

UNIVERSITY OF PANGASINAN O.R. SCRUB FORM

COLLEGE OF NURSING Major
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB in
(Hospital/Home/Lying-in Clinic, Municipality, City, Province)

Prepared by:
Name of Student: Signature of Student:

I. MAJOR OPERATIONS
TIME of
DATE of OPERATION PATIENT’S INITIALS OPERATION TYPE of Name & Signature of
No. DIAGNOSIS NAME of SURGEON Qualified Clinical Instructor
OPERATION STARTED- PERFORMED ANESTHESIA
ENDED CASE NO.

Noted by: PROF. ZENAIDA M. BAUTISTA Concurred by:

Clinical Coordinator Chief Nurse
PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: Valid Until:
PNA No.: 029069 Valid Until: October 31, 2010 PNA 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:

Approved by: PROF. MARIA TERESA R. FAJARDO

Supervised by: Dean
Clinical Instructor PRC I.D. No.: 0160104 Valid Until: September 9, 2010
Date signed: PNA No.: 013739 Valid Until: October 31, 2010
Degree: ADPCN No.: Valid Until:
PRC I.D. No.: Valid Until: Date document is signed: Time: ODC Form 2B
PNA No.: Valid Until: UNIVERSITY OF PANGASINAN Please specify Highest Nursing Degree Earned: O.R. SCRUB FORM
Minor
 COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB in
(Hospital/Home/Lying-in Clinic, Municipality, City, Province)

Prepared by:
Name of Student: Signature of Student:

II. MINOR OPERATIONS

TIME of
DATE of OPERATION PATIENT’S INITIALS OPERATION TYPE of Name & Signature of
No. DIAGNOSIS NAME of SURGEON Qualified Clinical Instructor
OPERATION STARTED- PERFORMED ANESTHESIA
ENDED CASE NO.

Noted by: PROF. ZENAIDA M. BAUTISTA Concurred by:

Clinical Coordinator Chief Nurse
PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: Valid Until:
PNA No.: 029069 Valid Until: October 31, 2010 PNA 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:

Approved by: PROF. MARIA TERESA R. FAJARDO

Supervised by: Dean
Clinical Instructor PRC I.D. No.: 0160104 Valid Until: September 9, 2010
Date signed: PNA No.: 013739 Valid Until: October 31, 2010
Degree: ADPCN No.: Valid Until:
PRC I.D. No.: Valid Until: ODC Form 1A
Date document is signed: Time:
PNA No.: Valid Until: UNIVERSITY OF PANGASINAN Please specify Highest Nursing Degree Earned:
ACTUAL
DELIVERY FORM
COLLEGE OF NURSING
 Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

ACTUAL DELIVERY in
(Hospital/Home/Lying-in Clinic, Municipality, City, Province)

Prepared by:
Name of Student: Signature of Student:

III. ACTUAL DELIVERIES

MOTHER’S INITIALS DATE of TIME of GENDER of TYPE Name & Signature of
No. DIAGNOSIS AGE
CASE NO. DELIVERY DELIVERY BABY of DELIVERY Qualified Clinical Instructor

Noted by: PROF. ZENAIDA M. BAUTISTA Concurred by:

Clinical Coordinator Chief Nurse
PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: Valid Until:
PNA No.: 029069 Valid Until: October 31, 2010 PNA 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:

Approved by: PROF. MARIA TERESA R. FAJARDO

Supervised by: Dean
Clinical Instructor PRC I.D. No.: 0160104 Valid Until: September 9, 2010
Date signed: PNA No.: 013739 Valid Until: October 31, 2010
Degree: ADPCN No.: Valid Until: ODC Form 1C
PRC I.D. No.: Valid Until: Date document is signed: Time:
PNA No.: Valid Until: UNIVERSITY OF PANGASINAN Please specify Highest Nursing Degree Earned:
ASSISTED
DELIVERY FORM
COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
 (Level I PACUCOA; Year Granted: March 05, 2007)

ASSISTED DELIVERY in
(Hospital/Home/Lying-in Clinic, Municipality, City, Province)

Prepared by:
Name of Student: Signature of Student:

IV. ASSISTED DELIVERIES

MOTHER’S INITIALS DATE of TIME of GENDER of TYPE Name & Signature of
No. DIAGNOSIS AGE
CASE NO. DELIVERY DELIVERY BABY of DELIVERY Qualified Clinical Instructor

Noted by: PROF. ZENAIDA M. BAUTISTA Concurred by:

Clinical Coordinator Chief Nurse
PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: Valid Until:
PNA No.: 029069 Valid Until: October 31, 2010 PNA 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:

Approved by: PROF. MARIA TERESA R. FAJARDO

Supervised by: Dean
Clinical Instructor PRC I.D. No.: 0160104 Valid Until: September 9, 2010
Date signed: PNA No.: 013739 Valid Until: October 31, 2010
Degree: ADPCN No.: Valid Until:
PRC I.D. No.: Valid Until: Date document is signed: Time: ODC Form 1C
PNA No.: Valid Until: UNIVERSITY OF PANGASINAN Please specify Highest Nursing Degree Earned: CORD CARE FORM
COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)
 IMMEDIATE NEWBORN CORD CARE in
(Hospital/Home/Lying-in Clinic, Municipality, City, Province)

Prepared by:
Name of Student: Signature of Student:

V. IMMEDIATE NEWBORN CORD CARE

DATE TIME OF BABY’S INITIALS Name & Signature of
No. GENDER of BABY MOTHER’S INITIALS AGE
PERFORMED DELIVERY CASE NO. Qualified Clinical Instructor

Noted by: PROF. ZENAIDA M. BAUTISTA Concurred by:

Clinical Coordinator Chief Nurse
PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PRC I.D. No.: Valid Until:
PNA No.: 029069 Valid Until: October 31, 2010 PNA 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:

Approved by: PROF. MARIA TERESA R. FAJARDO

Supervised by: Dean
Clinical Instructor PRC I.D. No.: 0160104 Valid Until: September 9, 2010
Date signed: PNA No.: 013739 Valid Until: October 31, 2010
Degree: ADPCN No.: Valid Until:
PRC I.D. No.: Valid Until: Date document is signed: Time:
PNA No.: Valid Until: Please specify Highest Nursing Degree Earned: