ODC Form 1A

OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: KAIZIRIN O. SALINAS

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

ODC Form 1A
OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: AICCA REANNA S. DESIPEDA

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

ODC Form 1A
OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: MARY JOY V. COPINO

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

ODC Form 1A
OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: ANGELA B. COPE

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

ODC Form 1A
OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: GINA R. CARULLO

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

ODC Form 1A
OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: JAMELA FAYE M. BAYABAN

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

ODC Form 1A
OR SCRUB FORM

Republic of the Philippines

AMANDO COPE COLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
SURGICAL SCRUB in BICOL REGIONAL TRAINING and TEACHING HOSPITAL, Daraga, Albay
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: MARLA F. ARANDELA

Date Performed and

Time Started

Patients INITIALS(only)
Case Number

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

SURGICAL PROCEDURE
PERFORMED

Approved by:

OR Nurse On Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD