Prc Form
OLIVAREZ COLLEGE
Dr. Arcadio Santos (Sucat Road), Parañaque City
Tel. No.: 825-7189/825-7119/826-0750 Fax No.: 825-8712
Website: www.olivarezcollege.edu.ph Email: pr.olivarezcollege@gmail.com
PACUCOA, PAASCU Level II 3rdReaccredited, September 10, 2011
SURGICAL SCRUB in __________________________ Name of Hospital
Prepared By:
Name of Student: _____________ Signature of Student: ______________________
Date Performed and Time Started | Patient’s INITIALS (Only)Case Number | SURGICAL PROCEDURE PERFORMED | O.R Nurse on Duty(Name Only) | SUPERVISED BYClinical Instructor(Name and Signature) | | | | | | | | | | | | | | | |
Noted By: Approved By:
__________________________________ _____________________________________
ALFREDO P. YAMBAO I, RN, RM, MAN ROBERTO C. SOMBILLO, RN, RM, PhD
Clinical Coordinator, College of Health Related Science Dean, College of Health Related Sciences
PRC I.D. No.: 0229013 Valid Until: December 18, 2014 PRC I.D. No.: 0172832 Valid Until: August 2, 2013
PNA I.D No.: 2013-005901Valid Until: October 31, 2013 PNA I.D No.:024661 Valid Until: LIFETIME
Date Signed: _________ Time: ________ Date Signed: ___________ Time: ________
Highest Nursing Degree Earned: MA in Nursing Highest Nursing Degree Earned: Doctor of Philosophy in Nursing Education
OLIVAREZ COLLEGE
Dr. Arcadio Santos (Sucat Road), Parañaque City
Tel. No.: 825-7189/825-7119/826-0750 Fax No.: 825-8712
Website: www.olivarezcollege.edu.ph Email: pr.olivarezcollege@gmail.com
PACUCOA, PAASCU Level II 2nd Reaccredited, September 10, 2011
CIRCULATING SCRUB in __________________________ Name of Hospital
Prepared By:
Name of Student: _________________ Signature of Student: ______________________
Date Performed and Time Started | Patient’s INITIALS (Only)Case Number | SURGICAL PROCEDURE PERFORMED | O.R Nurse on Duty(Name
Dr. Arcadio Santos (Sucat Road), Parañaque City
Tel. No.: 825-7189/825-7119/826-0750 Fax No.: 825-8712
Website: www.olivarezcollege.edu.ph Email: pr.olivarezcollege@gmail.com
PACUCOA, PAASCU Level II 3rdReaccredited, September 10, 2011
SURGICAL SCRUB in __________________________ Name of Hospital
Prepared By:
Name of Student: _____________ Signature of Student: ______________________
Date Performed and Time Started | Patient’s INITIALS (Only)Case Number | SURGICAL PROCEDURE PERFORMED | O.R Nurse on Duty(Name Only) | SUPERVISED BYClinical Instructor(Name and Signature) | | | | | | | | | | | | | | | |
Noted By: Approved By:
__________________________________ _____________________________________
ALFREDO P. YAMBAO I, RN, RM, MAN ROBERTO C. SOMBILLO, RN, RM, PhD
Clinical Coordinator, College of Health Related Science Dean, College of Health Related Sciences
PRC I.D. No.: 0229013 Valid Until: December 18, 2014 PRC I.D. No.: 0172832 Valid Until: August 2, 2013
PNA I.D No.: 2013-005901Valid Until: October 31, 2013 PNA I.D No.:024661 Valid Until: LIFETIME
Date Signed: _________ Time: ________ Date Signed: ___________ Time: ________
Highest Nursing Degree Earned: MA in Nursing Highest Nursing Degree Earned: Doctor of Philosophy in Nursing Education
OLIVAREZ COLLEGE
Dr. Arcadio Santos (Sucat Road), Parañaque City
Tel. No.: 825-7189/825-7119/826-0750 Fax No.: 825-8712
Website: www.olivarezcollege.edu.ph Email: pr.olivarezcollege@gmail.com
PACUCOA, PAASCU Level II 2nd Reaccredited, September 10, 2011
CIRCULATING SCRUB in __________________________ Name of Hospital
Prepared By:
Name of Student: _________________ Signature of Student: ______________________
Date Performed and Time Started | Patient’s INITIALS (Only)Case Number | SURGICAL PROCEDURE PERFORMED | O.R Nurse on Duty(Name