Notre Dame University College of Health Sciences Notre Dame Avenue, Cotabato City Tel. (064) 421-2698 Loc.

307, Telefax No. (064) 421-4312, E-mail Address: nducotabato.org PAASCU Level I: November 30 1984 IMMEDIATE NEWBORN CORD CARE In IMMEDIATE NEWBORN CORD CARE In Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student Patients INITIALS Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/ Homes) Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)

ICNB Form IMMEDIATE CARE OF THE NEWBORN FORM

Date Performed and Time Started

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until Time

Approved by: (Print name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned:

Valid Until Time

Notre Dame University College of Health Sciences Notre Dame Avenue, Cotabato City Tel. (064) 421-2698 Loc. 307, Telefax No. (064) 421-4312, E-mail Address: nducotabato.org PAASCU Level I: November 30 1984 ACTUAL DELIVERY In ACTUAL DELIVERY In Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student Patients INITIALS Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/ Homes) PROCEDURE PERFORMED ASSISTED DELIVERY D. R. Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)

D. R. Form 1B ASSISTED DELIVERY FORM

Date Performed and Time Started

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until Time

Approved by: (Print name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned:

Valid Until Time

Notre Dame University College of Health Sciences Notre Dame Avenue, Cotabato City Tel. (064) 421-2698 Loc. 307, Telefax No. (064) 421-4312, E-mail Address: nducotabato.org PAASCU Level I: November 30 1984 ACTUAL DELIVERY In ACTUAL DELIVERY In Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student Patients INITIALS Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/ Homes) PROCEDURE PERFORMED D. R. Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)

D. R. Form 1A ACTUAL DELIVERY FORM

Date Performed and Time Started

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until Time

Approved by: (Print name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned:

Valid Until Time

Notre Dame University College of Health Sciences Notre Dame Avenue, Cotabato City Tel. (064) 421-2698 Loc. 307, Telefax No. (064) 421-4312, E-mail Address: nducotabato.org PAASCU Level I: November 30 1984 SURGICAL SCRUB In SURGICAL SCRUB In Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student Date Performed and Time Started Patients INITIALS Only Case Number

O. R. Form 1A O. R. SCRUB FORM Major

SURGICAL PROCEDURE PERFORMED

O. R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until Time

Approved by: (Print name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned:

Valid Until Time

Notre Dame University College of Health Sciences Notre Dame Avenue, Cotabato City Tel. (064) 421-2698 Loc. 307, Telefax No. (064) 421-4312, E-mail Address: nducotabato.org PAASCU Level I: November 30 1984 SURGICAL CIRCULATING In SURGICAL SCRUB In Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student Patients INITIALS Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/ Homes) PROCEDURE PERFORMED Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)

O. R. Form 1B O. R. CIRCULATING FORM

Date Performed and Time Started

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until Time

Approved by: (Print name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned:

Valid Until Time

College of Health Sciences Notre Dame Avenue, Cotabato City Tel. (064) 421-2698 Loc. 307, Telefax No. (064) 421-4312, E-mail Address: nducotabato.org PAASCU Level I: November 30 1984 SURGICAL SCRUB In SURGICAL SCRUB In Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student Patients INITIALS Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/ Homes) PROCEDURE PERFORMED Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)

O. R. Form 1B O. R. CIRCULATING FORM

Date Performed and Time Started

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until Time

Approved by: (Print name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned:

Valid Until Time