ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy.
87, Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs SURGICAL SCRUB in ____________________________________________________ Hospital, Municipality / City / Province Prepared by: Printed Name with Signature of Student: _______________________________________________________ Date Performed and Time Started Patient's INITIALS (only) Case Number O.R. Nurse On Duty (Name and Signature) O.R. Form 1A MAJOR SURGERY
SURGICAL PROCEDURE PERFORMED
SUPERVISED BY Clinical Instructor (Name and Signature)
PRC NUMBER: PNA NUMBER VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
OVER-ALL CLINICAL COORDINATOR
PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: ADPCN: VALID UNTIL:
DEAN
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________
Page No. ___________________ Book No. ___________________ Series of 2011
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL DELIVERY in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
D.R. Form ACTUAL D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
PROCEDURE PERFORMED
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs IMMEDIATE NEWBORN CORD CARE in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form IMMEDI SUPERVISED BY Clinical Instructor Name and Signature
Nurse On Duty Immediate Newborn Cord Care (Name and Signature) (If PERFORMED Indicate where Midwife on Duty, Signature not performed e.g. D.R., Nursery, NICU, or Home Required)
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011 ST. SCHOLASTICA'S COLLEGE TACLOBAN
Signature over Printed Name
COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL ASSIST in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form ACTUAL SUPERVISED BY Clinical Instructor Name and Signature
Nurse On Duty Actual Assist PERFORMED (Name and Signature) (If Indicate where performed e.g. D.R., Nursery, NICU, or Midwife on Duty, Signature not Home Required)
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs SURGICAL SCRUB in ____________________________________________________ Hospital, Municipality / City / Province Prepared by: Printed Name with Signature of Student: _______________________________________________________ Date Performed and Time Started Patient's INITIALS (only) Case Number O.R. Nurse On Duty (Name AND Signature)
PRC NUMBER: PNA NUMBER
O.R. Form 1A MINOR SURGERY
SURGICAL PROCEDURE PERFORMED
SUPERVISED BY Clinical Instructor Name and Signature
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
OVER-ALL CLINICAL COORDINATOR
PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: ADPCN: VALID UNTIL:
DEAN
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________
Page No. ___________________ Book No. ___________________ Series of 2011
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL DELIVERY in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
D.R. Form ACTUAL D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
PROCEDURE PERFORMED
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs IMMEDIATE NEWBORN CORD CARE in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form IMMEDI SUPERVISED BY Clinical Instructor Name and Signature
Nurse On Duty (Name Immediate Newborn Cord Care and Signature) (If Midwife PERFORMED Indicate where on Duty, Signature not performed e.g. D.R., Nursery, NICU, or Home Required)
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011 ST. SCHOLASTICA'S COLLEGE TACLOBAN
Signature over Printed Name
COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL ASSIST in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form ACTUAL Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
Actual Assist PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL DELIVERY in ____________________________________________________ Hospital, Municipality / City / Province Prepared by: Printed Name with Signature of Student: _______________________________________________________ Date Performed and Time Started Patient's INITIALS (only) Case Number O.R. Nurse On Duty (Name and Signature) D.R. FORM ACTUAL DELIVERY FORM SUPERVISED BY Clinical Instructor (Name and Signature)
PRC NUMBER: PNA NUMBER VALID UNTIL: VALID UNTIL:
PROCEDURE PERFORMED
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
OVER-ALL CLINICAL COORDINATOR
PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: ADPCN: VALID UNTIL:
DEAN
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________
Page No. ___________________ Book No. ___________________ Series of 2011
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL DELIVERY in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
D.R. Form ACTUAL D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
PROCEDURE PERFORMED
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs IMMEDIATE NEWBORN CORD CARE in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form IMMEDI SUPERVISED BY Clinical Instructor Name and Signature
Nurse On Duty (Name Immediate Newborn Cord Care and Signature) (If Midwife PERFORMED Indicate where on Duty, Signature not performed e.g. D.R., Nursery, NICU, or Home Required)
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011 ST. SCHOLASTICA'S COLLEGE TACLOBAN
Signature over Printed Name
COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL ASSIST in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form ACTUAL Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
Actual Assist PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs CORD CARE in ____________________________________________________ Hospital, Municipality / City / Province Prepared by: Printed Name with Signature of Student: _______________________________________________________ Date Performed and Time Started Patient's INITIALS (only) Case Number IMMEDIATE NEWBORN CORD CARE PERFORMED Nurse On Duty (Name and Signature)
PRC NUMBER: PNA NUMBER
IMMEDIATE NEWBORN CORD CARE FORM
SUPERVISED BY Clinical Instructor Name and Signature
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
OVER-ALL CLINICAL COORDINATOR
PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: ADPCN: VALID UNTIL:
DEAN
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________
Page No. ___________________ Book No. ___________________ Series of 2011
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL DELIVERY in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
D.R. Form ACTUAL D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
PROCEDURE PERFORMED
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs IMMEDIATE NEWBORN CORD CARE in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form IMMEDI SUPERVISED BY Clinical Instructor Name and Signature
Nurse On Duty (Name Immediate Newborn Cord Care and Signature) (If Midwife PERFORMED Indicate where on Duty, Signature not performed e.g. D.R., Nursery, NICU, or Home Required)
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011 ST. SCHOLASTICA'S COLLEGE TACLOBAN
Signature over Printed Name
COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL ASSIST in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form ACTUAL Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
Actual Assist PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Brgy. 87, Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ASSISTED DELIVERY in ____________________________________________________ Hospital, Municipality / City / Province Prepared by: Printed Name with Signature of Student: _______________________________________________________ Date Performed and Time Started Patient's INITIALS (only) Case Number D.R. Nurse On Duty (Name and Signature)
PRC NUMBER: PNA NUMBER
ASSISTED DELIVERY FORM
PROCEDURE PERFORMED
SUPERVISED BY Clinical Instructor Name and Signature
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
PRC NUMBER: PNA NUMBER
VALID UNTIL: VALID UNTIL:
OVER-ALL CLINICAL COORDINATOR
PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: PRC NUMBER: VALID UNTIL: PNA NUMBER: VALID UNTIL: ADPCN: VALID UNTIL:
DEAN
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions, laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________
Page No. ___________________ Book No. ___________________ Series of 2011
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL DELIVERY in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
D.R. Form ACTUAL D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
PROCEDURE PERFORMED
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
ST. SCHOLASTICA'S COLLEGE TACLOBAN COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs IMMEDIATE NEWBORN CORD CARE in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form IMMEDI SUPERVISED BY Clinical Instructor Name and Signature
Nurse On Duty (Name Immediate Newborn Cord Care and Signature) (If Midwife PERFORMED Indicate where on Duty, Signature not performed e.g. D.R., Nursery, NICU, or Home Required)
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011 ST. SCHOLASTICA'S COLLEGE TACLOBAN
Signature over Printed Name
COLLEGE OF NURSING & MIDWIFERY Manlurip, San Jose, Tacloban City Tel. No. (053) 325-2188 loc. 203 / Fax No. (053) 325-4089 / web.evis.net.ph/sschs ACTUAL ASSIST in ____________________________________________________ Hospital / Home/ Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student ___________________________________________ Date Performed and Time Started Patient's INITIALS (only)
Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)
ICNB Form ACTUAL Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature
Actual Assist PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home
Certified True and Correct:
Clinical Coordinator License Number: __________________ PRC Card-Validity Date:_____________
Dean License Number: ________________ PRC Card-Validity Date:___________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct and complete statement pursuant to the provisions of pertinent laws, rules and regulations of the Republic of the Philippines. Subscribed and sworn before me this ________ day of _________________, 2011, Philippines. Doc. No. ___________________ Page No. ___________________ Book No. ___________________ Series of 2011
Signature over Printed Name
