Amando Cope Colege College of Nursing: ODC Form 1A

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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 DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital, Municipality/City Province
Prepared by:
Printed Name with Signature of Student:

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:
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
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD

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