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UNIVERSITY OF SAN JOSE-RECOLETOS ODC Form 2A

  COLLEGE OF NURSING, CORNER P. LOPEZ ST & MAGALLANES ST CEBU CITY PHILIPPINES 6000 O.R. SCRUB FORM

PHONE: 032 253 7900 Loc 543; FAX: 032254 1720;www.usjr.edu.ph MAJOR

SURGICAL SCRUB in SALVACION OPPUS YŇIGUEZ MEMORIAL PROVINCIAL HOSPITAL ,MAASIN CITY, SOUTHERN LEYTE

Hospital, Municipality/City/Province

Prepared by:

Printed Name with Signature of Student: PONTEVEDRA, ARMIE C.

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|Date Performed and |Patient’s INITIALS (only) | |O.R. Nurse On Duty |SUPERVISED BY |

|Time Started | |SURGICAL PROCEDURE PERFORMED |(Name and Signature) |Clinical Instructor |

| | | | |(Name and Signature) |

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