INP Forms

PAMANTASAN NG CABUYAO
KATAPATAN HOMES, BANAY-BANAY, CABUYAO LAGUNA
COLLEGE OF NURSING
STUDENT TRAINING AGREEMENT AND LIABILITY WAIVER
I ______________________________, fourth year student of College of Nursing, do hereby voluntarily undergo Intensive Nursing Practicum hereinafter referred to under the following terms and conditions: a. That the total number of hours required for me to complete my Intensive Nursing Practicum is 40 hours in Industry. b. That I shall abide by the institutional rules and regulations and shall comply with the policies and standards of my practicum. c. That the time I will spend on my practicum in the completion of the training requirements will not and should not be interpreted as working hours and should be regarded as non-compensable. d. That I shall personally be made answerable for any liabilities or for damage to property or injury to third person, which maybe occasioned by my intention or negligent acts during the course of my Intensive Nursing Practicum. e. That I shall likewise hold the company and Pamantasan ng Cabuyao free from any liability and responsibility for any sickness or injury to myself and third parties and damage to property which I may sustain and/or may occur at any time during my practicum period including time spent in traveling to and from any and all premises and locations where I may be required to go to as part of my Intensive Nursing Practicum. f. That if I fail to do in accordance to the companys rules and regulations and with the schools policies, I will be subjected to disciplinary action and this can be a ground for disqualification from my graduation.
________________________________ Student Name and Signature
With our consent:
_________________________________ Parents/Guardians Name and Signature
Conforme:
_________________________________ CLINICAL INSTRUCTOR
_________________________________ Name of Company Representative
_________________________________ HERMAN F. ZOLETA, RN MAN Dean, College of Nursing
_________________________________ Position in the Company
COLLEGE OF NURSING
LETTER OF ACCEPTANCE
After reviewing the documents presented to this institution, we are certifying that Mr. /Ms. _________________________________ has been accepted to undergo Intensive Nursing Practicum for the period _______________________ to _____________________. It is understood that the said student will complete ____________ hours.
We are also certifying that proper orientation shall be given to the concerned before the start of the Intensive Nursing Practicum.
___________________________________ SIGNATURE ABOVE PRINTED NAME
(Please provide the needed information below.)
NAME: ______________________________________________ POSITION: __________________________________________ NAME OF THE INSTITUTION: _________________________ ADDRESS: __________________________________________ CONTACT NUMBER: _________________________________
COLLEGE OF NURSING
INTENSIVE NURSING PRACTICUM PERFORMANCE EVALUATION

Student Name: __________________________________ Course: __________________________ Department Assigned: ______________________________________________________________ Field of Training Given: ____________________________________________________________ Inclusive Date of Practicum: From: ________________________ To: ________________________ Total Number of Hours Rendered by the Trainees: ________________________________________
*Provide rating in the box provided in percentage. (To be filled up by a representative where the student completed his/her practicum period.)
Competencies/Factor I. KNOWLEDGE COMPETENCY - 30%

1. Utilizes the nursing process in assessing health hazards in the workplace. 2. Application of knowledge in terms of handling clients who exhibits complaints from disease or injury in the workplace. 3. Able to apply organizing, planning, directing and controlling as a team player in the institution
Rating
Remarks
II. SKILLS COMPETENCY - 50% 1. Assessment

A. Utilizes appropriate and varied resources for assessment: Nursing History, Physical Examination, ongoing Observation, and Records/Report. B. Analyzes the date gathered based on scientific concepts and principles.
2. Planning
A. Sets priorities of clients problems/needs. B. Formulates attainable and measurable objectives according to the development stage of clients C. Formulates attainable and specific objectives in the areas of assignment. D. Utilizes varied available resources in planning of care: medical care plan, client resources, and support system. E. Anticipated possible outcomes of nursing intervention based on the areas of expertise. F. Make decisions for the alternative course of action to be implemented based on the situation.
3. Intervention
A. Organizes work according to priority of clients needs and/or problems B. Utilizes available resources in meeting the clients needs and/or problems C. Carries out nursing interventions based on scientific principles with consideration for clients: bio-physical spiritual status, safety, comfort, privacy, economy of time, economy of materials, and economy of effort and neatness of work.
D. Modifies nursing approaches to meet clients needs and/or problems E. Reports and records appropriately all necessary information
4. Evaluation
A. Evaluates effectiveness of the total nursing care based on objectives formulated in the areas of assignment B. Identifies factors that influence, facilitate/or block the attainment of objectives.
III. PERSONAL ATTRIBUTES/CORE VALUES 20%

A. Maintain good health and vitality B. Reports on duty with the require attire C. Appears well groomed and maintain good poise while on duty D. Has sense of responsibility E. Mentally, Emotional, and physically healthy F. Alert and resourceful
G. Observe economy of time, materials and effort H. Cooperative and considerate to others I. Avail self of opportunity for learning J. Inform authority about own mistakes and/or significant incidents despite personal fear of difficulty. K. Accepts suggestions and criticisms graciously and show effort to overcome shortcomings and liabilities. L. Has reasonable control of emotions M. Always present and punctual N. Show gracefulness even under pressure.
OVER ALL PERFORMANCE RATING
Please write your general comments: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ________________________________________________________________________________
____________________________________________ Trainees Supervisor Signature over Printed Name
COLLEGE OF NURSING
CERTIFICATION OF COMPLETION
This is to certify that Mr. / Ms. ___________________________________________ has successfully completed his/her Intensive Nursing Practicum in _________________ area covering _________ hours/days during the period from _________________ to _____________________ 2012-2013.
This certification is being issued in compliance with the requirements of Pamantasan ng Cabuyao.
_________________________________ SIGNATURE ABOVE PRINTED NAME
_________________________________ Position
________________________________ Date of Issue
PAMANTASAN NG CABUYAO BANAY-BANAY, CABUYAO LAGUNA COLLEGE OF NURSING INTENSIVE NURSING PRACTICUM
STUDENT TIME RECORD
Student Name: _________________________________________ Institution Name: _______________________________________ Address: ______________________________________________ Contact Number: _______________________________________
Day Arrival 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 A.M Departure Arrival P.M Departure Overtime Hours Minutes
23 24 25 26 27 28 29 30 31 Total I certify under oath that the data are true and correct entries of my hours of work performed, record of which were made daily at the time of arrival and departure from office. ________________________ Student Signature Verified Correct:
_________________ Clinical Instructor
_________________ Institution Head
___________________ Officer In Charge

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PAMANTASAN NG CABUYAO

KATAPATAN HOMES, BANAY-BANAY, CABUYAO LAGUNA

STUDENT TRAINING AGREEMENT AND LIABILITY WAIVER

________________________________ Student Name and Signature

With our consent:

_________________________________ Parents/Guardians Name and Signature

_________________________________ CLINICAL INSTRUCTOR

_________________________________ Name of Company Representative

_________________________________ HERMAN F. ZOLETA, RN MAN Dean, College of Nursing

_________________________________ Position in the Company

___________________________________ SIGNATURE ABOVE PRINTED NAME

(Please provide the needed information below.)

INTENSIVE NURSING PRACTICUM PERFORMANCE EVALUATION

Competencies/Factor I. KNOWLEDGE COMPETENCY - 30%

II. SKILLS COMPETENCY - 50% 1. Assessment

III. PERSONAL ATTRIBUTES/CORE VALUES 20%

OVER ALL PERFORMANCE RATING

____________________________________________ Trainees Supervisor Signature over Printed Name

_________________________________ SIGNATURE ABOVE PRINTED NAME

________________________________ Date of Issue

STUDENT TIME RECORD

_________________ Clinical Instructor

_________________ Institution Head

___________________ Officer In Charge

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