ODC Form

2A O.R.
SCRUB FORM
VISAYAS STATE UNIVERSITY Major
ViSCA, BAYBAY, LEYTE 6521 - A
(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph
ACCREDITED: AACCUP LEVEL II, November 22-26, 2010

SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ______________________________________________

Date Patient’s INITIALS SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY

Performed (only)
(Name AND Clinical Instructor
and Case Number PERFORMED
Signature)
Name and Signature
Time Started

Noted by: _______________________________________________ Approved by:

___________________________________________________ (Print Name and Signature) (Print
Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until: ____________ Dean, PRC I.D. No. ____________________ Valid Until:
__________________________ Date document is signed: _________________________ Time: ___________________ Date document is signed:
______________________ Time: ________________________ Please specify Highest Nursing Degree Earned: ________________________________ Specify Highest
Nursing Degree Earned: _______________________________________
(STRICTLY NO DESIGNATES)
 ODC Form
2B O.R.
MINOR FORM
VISAYAS STATE UNIVERSITY
ViSCA, BAYBAY, LEYTE 6521 - A
(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph
ACCREDITED: AACCUP LEVEL II, November 22-26, 2010

SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ______________________________________________

Date Patient’s INITIALS SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY

Performed (only)
(Name and Clinical Instructor
and Case Number PERFORMED
Signature)
Name and Signature
Time Started

Noted by: _______________________________________________ Approved by:

___________________________________________________ (Print Name and Signature) (Print
Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until: ____________ Dean, PRC I.D. No. ____________________ Valid Until:
__________________________ Date document is signed: _________________________ Time: _ __________________ Date document is signed:
______________________ Time: ________________________ Please specify Highest Nursing Degree Earned: ________________________________ Specify Highest
Nursing Degree Earned: _______________________________________
(STRICTLY NO DESIGNATES)
 ODC Form 1A
ACTUAL DELIVERY
FORM
VISAYAS STATE UNIVERSITY
ViSCA, BAYBAY, LEYTE 6521 - A
(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph
ACCREDITED: AACCUP LEVEL II, November 22-26, 2010

SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ______________________________________________

Date Patient’s INITIALS PROCEDURE D.R. Nurse On Duty SUPERVISED BY

Performed (only)
PERFORMED (Name and Clinical Instructor
and Case Number
Signature)
Name and Signature
Time Started (not applicable for
(If Midwife on
Birthing/Lying
Duty, Signature
In Clinics/Homes) Not

Required)
Noted by: _______________________________________________ Approved by:
___________________________________________________ (Print Name and Signature) (Print
Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until: ____________ Dean, PRC I.D. No. ____________________ Valid Until:
__________________________ Date document is signed: _________________________ Time: ___________________ Date document is signed:
______________________ Time: ________________________ Please specify Highest Nursing Degree Earned: ________________________________ Specify Highest
Nursing Degree Earned: _______________________________________

(STRICTLY NO DESIGNATES)
 ODC Form 1B
ASSISTED
DELIVERY FORM
VISAYAS STATE UNIVERSITY
ViSCA, BAYBAY, LEYTE 6521 - A
(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph
ACCREDITED: AACCUP LEVEL II, November 22-26, 2010

SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ______________________________________________

Date Patient’s INITIALS PROCEDURE D.R. Nurse On Duty SUPERVISED BY

Performed (only)
PERFORMED (Name and Clinical Instructor
and Case Number
Signature)
Name and Signature
Time Started (not applicable for
Birthing/Lying (If Midwife on
ASSISTED DELIVERY Duty, Signature
In Clinics/Homes)
Not

Required)
Noted by: _______________________________________________ Approved by:
___________________________________________________ (Print Name and Signature) (Print
Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until: ___________ Dean, PRC I.D. No. ____________________ Valid Until:
__________________________ Date document is signed: _________________________ Time : __________________ Date document is signed: ______________________ Time:
_______________________ Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned:
_______________________________________

(STRICTLY NO DESIGNATES)
 ODC Form 1C
CORD CARE FORM

VISAYAS STATE UNIVERSITY

ViSCA, BAYBAY, LEYTE 6521 - A
(63) (053) 335-2601/ (63) (053) 335-2601/ http://www.vsu.edu.ph
ACCREDITED: AACCUP LEVEL II, November 22-26, 2010

SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student ______________________________________________

Date Patient’s INITIALS Immediate Newborn Cord Care D.R. Nurse On Duty SUPERVISED BY
Performed (only)
PERFORMED (Name and Clinical Instructor
and Case Number
Signature)
Indicate where performed e.g. D.R., Name and Signature
Time Started (not applicable for Nursery,
Birthing/Lying (If Midwife on
NICU, or Home Duty, Signature
In Clinics/Homes)
Not

Required)
Noted by: _______________________________________________ Approved by:
___________________________________________________ (Print Name and Signature) (Print
Name and Signature)
Clinical Coordinator, PRC I.D No. ________________ Valid Until: ___________ Dean, PRC I.D. No. ____________________ Valid Until:
__________________________ Date document is signed: _________________________ Time: __________________ Date document is signed: ______________________ Time:
________________________ Please specify Highest Nursing Degree Earned: _______________________________ Specify Highest Nursing Degree Earned:
_______________________________________

(STRICTLY NO DESIGNATES)