Republic of the Philippines ODC Form 2A

CAVITE STATE UNIVERSITY O.R SCRUB FORM

(CvSU) Major
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in MV Santiago Medical Center Trece Martirez City, Cavite

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

D.M.T. JOCELYN B. DIMAYUGA, RN, MAN

April 26, 2010 Cesarian Section Vanessa Rodil, RN PRC No.: 0263292 Valid Until: November 6, 2011
10:28pm 01696 PNA No.: 2011-106608 Valid Until: October 30, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________
 Republic of the Philippines ODC Form 2A
CAVITE STATE UNIVERSITY O.R SCRUB FORM
(CvSU) Major
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in Batangas Regional Hospital, Batangas City

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

C.J.M. ANABELLE M. ITURRALDE, MD, RN, MAN

September 4, 2010 Burrholling Craniectomy PRC No.: 0373171 Valid Until: October 23, 2011
1:34pm 458794 PNA No.: 2011- Valid Until: October 31, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________
 Republic of the Philippines ODC Form 2A
CAVITE STATE UNIVERSITY O.R SCRUB FORM
(CvSU) Major
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in Korea Philippines Friendship General Hospital Trece Martirez City

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

J.G.R. EVELYN M. DEL MUNDO, RN, MAN

July 31, 2010 Exploratory Laparotomy Marilen Paman, RN PRC No.: 0130620 Valid Until: June 12, 2012
4:08pm 191422 PNA No.: 2011-106604 Valid Until: October 31, 2011
Date Signed: _________________

A.P.F. EVELYN M. DEL MUNDO, RN, MAN

December 6, 2010 Endoscopic Sinus Surgery Marilen Paman, RN PRC No.: 0130620 Valid Until: June 12, 2012
9:38am 198016 Under GA PNA No.: 2011-106604 Valid Until: October 31, 2011
Date Signed: _________________

E.Q.S. EVELYN M. DEL MUNDO, RN, MAN

December 22, 2010 Myomectomy Marilen Paman, RN PRC No.: 0130620 Valid Until: June 12, 2012
9:58am 228019 PNA No.: 2011-106604 Valid Until: October 31, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________
 Republic of the Philippines ODC Form 2B
CAVITE STATE UNIVERSITY O.R MINOR FORM
(CvSU)
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in MV Santiago Medical Center Trece Martirez City, Cavite

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

P.R.S. JOCELYN B. DIMAYUGA, RN, MAN

September 4, 2010 Circumcision Eajeve Lupisan, RN PRC No.: 0263292 Valid Until: November 6, 2011
8:00am OPD PNA No.: 2011-106608 Valid Until: October 30, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________
 Republic of the Philippines
CAVITE STATE UNIVERSITY ODC Form 2B
(CvSU) O.R MINOR FORM
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in San Lorenzo Ruiz Hospital Naic, Cavite

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

A.J.M. DIVINA JOY TUZON RN, MSN

May 11, 2010 Appendectomy Cecilia Hernandez, RN PRC No.: 043379 Valid Until: November 24, 2014
9:26pm 28792 PNA No.: 2011-106610 Valid Until: October 31, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________
 Republic of the Philippines
CAVITE STATE UNIVERSITY
(CvSU) ODC Form 2B
DON SEVERINO DE LAS ALAS CAMPUS O.R MINOR FORM
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in Tanza Family General Hospital, Tanza, Cavite

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

D.H.A. JULIUS U. TEPORA RN, MSN

August 20, 2010 Wound Suturing Leonil Miranda, RN PRC No.: 0413934 Valid Until: September 09, 2014
11:35am 02975 PNA No.: 2011-106612 Valid Until: October 31, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________

Republic of the Philippines

ODC Form 2B
O.R MINOR FORM
 CAVITE STATE UNIVERSITY
(CvSU)
DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in Batangas Regional Hospital, Batangas City

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

A.G.D. JOINITO A. OFRACIO RN, MAN©

December 7, 2010 Wound Suturing PRC No.: 0143781 Valid Until: June 02, 2011
2:35pm 468174 PNA No.: 2011- Valid Until: October 31, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________

Republic of the Philippines ODC Form 2B

CAVITE STATE UNIVERSITY O.R MINOR FORM
(CvSU)
 DON SEVERINO DE LAS ALAS CAMPUS
Indang, Cavite
(046) 415-0021/ (046) 415-0012
E-mail: cvsu@asia.com

COLLEGE OF NURSING

SURGICAL SCRUB in General Emilio Aguinaldo Memorial Hospital, Trece Martirez City, Cavite

Prepared by:

Printed Name with Signature of Student: STEPHANIE RAE L. POLITTUDE

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 PERFORMED Name and Signature

E.M.O. LEAH ANN H. BELTRAN, R.N, MAN

March 23, 2011 Bilateral Tubal Ligation PRC No.: 034679 Valid Until: August 2, 2011
4:59pm 202550 PNA No.:2011-106609 Valid Until:October 31, 2011
Date Signed: _________________

Noted by: NENITA B. PANALIGAN, RN, MAN Approved by: LENILA DE VERA, RN, MPH, MAN©
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0201832 Valid Until: March 01, 2014 Dean, PRC I.D No. 0083977 Valid Until: March 08, 2012
Date document is signed: ____________________ Time: ________________ Date document is signed: _____________ Time: ____________________
Please specify Highest Nursing Degree Earned: _________________________ Please specify Highest Nursing Degree Earned: _______________________