BATAAN PENINSULA STATE UNIVERSITY

COLLEGE OF NURSING AND MIDWIFERY

Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph
ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC.
(AACCUP)
3

Accredited by:
Level:
Date of
Accreditation:

O.R. Form 1-A

MAJOR O.R. SCRUB FORM

January 01, 2014

SURGICAL SCRUB IN
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student:

ARRA BEATRIZ G. CUBEBE

(Printed Name & Signature of Student)

Date
Performed
and Time
Started

Patients Initial Only

Case Number

(Not Applicable for Birthing/Lying-In,

Clinics/Homes)

Noted by:

SURGICAL PROCEDURE PEFORMED

Concurred:
ROSITA D. VIANZON
Clinical Coordinator

PRC I.D. no:

Valid until:
PNA no:
Valid until:
Date document is
signed:

Name and Signature

Supervised by
Clinical Instructor
Name and Signature

Approved by:
Chief Nurse

PRC I.D. no:

Valid until:
PNA no:
Valid until:
Date document is
signed:

O.R. Nurse on Duty

MA. FLORINDA O. RUBIANO

Dean
PRC I.D. no:
Valid until:
PNA no:
Valid until:
Date document is
signed:

Highest degree
earned:

Master of Arts in
Nursing

Highest degree
earned:

Highest degree
earned:

Master of Arts in
Nursing

BATAAN PENINSULA STATE UNIVERSITY

COLLEGE OF NURSING AND MIDWIFERY
Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph

Accredited by:
Level:
Date of
Accreditation:

ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC.

(AACCUP)
3
O.R. Form 1-A
MAJOR O.R. CIRCULATING

January 01, 2014

FORM

SURGICAL CIRCULATING IN
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student:

ARRA BEATRIZ G. CUBEBE

(Printed Name & Signature of Student)

Date
Performed
and Time
Started

Patients Initial Only

Case Number

(Not Applicable for Birthing/Lying-In,

Clinics/Homes)

Noted by:

SURGICAL PROCEDURE PEFORMED

Concurred:
ROSITA D. VIANZON
Clinical Coordinator

PRC I.D. no:

Valid until:
PNA no:
Valid until:

Name and Signature

Supervised by
Clinical Instructor
Name and Signature

Approved by:
Chief Nurse

PRC I.D. no:

Valid until:
PNA no:
Valid until:

O.R. Nurse on Duty

MA. FLORINDA O. RUBIANO

Dean
PRC I.D. no:
Valid until:
PNA no:
Valid until:

Date document is
signed:
Highest degree
earned:

Master of Arts in
Nursing

Date document is
signed:
Highest degree
earned:

Date document is
signed:
Highest degree
earned:

Master of Arts in
Nursing

BATAAN PENINSULA STATE UNIVERSITY

COLLEGE OF NURSING AND MIDWIFERY

Don Manuel Banzon Avenue, City of Balanga, Bataan

(047) 237-5477, mail@bpsu.edu.ph
ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC.
(AACCUP)
3

Accredited by:
Level:
Date of
Accreditation:

O.R. Form 1-A

MINOR O.R. SCRUB FORM

January 01, 2014

SURGICAL SCRUB IN
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student:

ARRA BEATRIZ G. CUBEBE

(Printed Name & Signature of Student)

Date
Performed
and Time
Started

Patients Initial Only

Case Number

(Not Applicable for Birthing/Lying-In,

Clinics/Homes)

Noted by:

SURGICAL PROCEDURE PEFORMED

Concurred:
ROSITA D. VIANZON
Clinical Coordinator

PRC I.D. no:

Valid until:

Name and Signature

Supervised by
Clinical Instructor
Name and Signature

Approved by:
Chief Nurse

PRC I.D. no:

Valid until:

O.R. Nurse on Duty

MA. FLORINDA O. RUBIANO

Dean
PRC I.D. no:
Valid until:

PNA no:
Valid until:
Date document is
signed:
Highest degree
earned:

Master of Arts in
Nursing

PNA no:
Valid until:
Date document is
signed:
Highest degree
earned:

PNA no:
Valid until:
Date document is
signed:
Highest degree
earned:

Master of Arts in
Nursing