FAR EASTERN UNIVERSITY
Nicanor Reyes Street Sampaloc, Manila, Philippines, 1015
Tel. No.: (+632) 849 - 4000, Fax No.: (+632) 849 - 4128, Email:
[email protected], Website: www.feu.edu.ph
Level III PAASCU Accredited, June 2018
MAJOR SURGICAL SCRUB in __________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student:
Patient’s INITIALS (only)
Date Performed SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse on Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started (Name and Signature)
Noted by: Approved by:
JENNIFER C. PADUAL, MAN, RN____________________ MOIRA G. UY, MAN, RN_____________________________
Signature over printed name of Clinical Coordinator for RLE Signature over printed name of Dean, Department of Nursing
Date Signed: Date Signed: _
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing _
PRC Lic. No.: 0326430 PRC Lic. No.: 0234646 _
Valid Until: August 8, 2024 Valid Until: January 17, 2025 _
PNA No.: M-61209 PNA No.: M-5637 _
Valid Until: December 31, 2023 Valid Until: December 31, 2023 _
FAR EASTERN UNIVERSITY
Nicanor Reyes Street Sampaloc, Manila, Philippines, 1015
Tel. No.: (+632) 849 - 4000, Fax No.: (+632) 849 - 4128, Email:
[email protected], Website: www.feu.edu.ph
Level III PAASCU Accredited, June 2018
MINOR SURGICAL SCRUB in __________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student:
Patient’s INITIALS (only)
Date Performed SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse on Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started (Name and Signature)
Noted by: Approved by:
JENNIFER C. PADUAL, MAN, RN____________________ MOIRA G. UY, MAN, RN_____________________________
Signature over printed name of Clinical Coordinator for RLE Signature over printed name of Dean, Department of Nursing
Date Signed: Date Signed: _
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing _
PRC Lic. No.: 0326430 PRC Lic. No.: 0234646 _
Valid Until: August 8, 2024 Valid Until: January 17, 2025 _
PNA No.: M-61209 PNA No.: M-5637 _
Valid Until: December 31, 2023 Valid Until: December 31, 2023 _
FAR EASTERN UNIVERSITY
Nicanor Reyes Street Sampaloc, Manila, Philippines, 1015
Tel. No.: (+632) 849 - 4000, Fax No.: (+632) 849 - 4128, Email:
[email protected], Website: www.feu.edu.ph
Level III PAASCU Accredited, June 2018
IMMEDIATE NEWBORN CARE in _________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student:
Patient’s INITIALS (only) Immediate Newborn Care D.R. Nurse on Duty
Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(Not applicable for Birthing/Lying-In (Indicate where performed e.g. (If Midwife on Duty,
Time Started (Name and Signature)
Clinics/Homes) D.R., Nursery, NICU, or Home) Signature not Required)
Noted by: Approved by:
JENNIFER C. PADUAL, MAN, RN____________________ MOIRA G. UY, MAN, RN____________________________
Signature over printed name of Clinical Coordinator for RLE Signature over printed name of Dean, Department of Nursing
Date Signed: Date Signed: _
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing _
PRC Lic. No.: 0326430 PRC Lic. No.: 0234646 _
Valid Until: August 8, 2024 Valid Until: January 17, 2025 _
PNA No.: M-61209 PNA No.: M-5637 _
Valid Until: December 31, 2023 Valid Until: December 31, 2023 _
FAR EASTERN UNIVERSITY
Nicanor Reyes Street Sampaloc, Manila, Philippines, 1015
Tel. No.: (+632) 849 - 4000, Fax No.: (+632) 849 - 4128, Email:
[email protected], Website: www.feu.edu.ph
Level III PAASCU Accredited, June 2018
ACTUAL DELIVERY in _________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student:
Patient’s INITIALS (only) D.R. Nurse on Duty
Date Performed SUPERVISED BY
Case Number PROCEDURE PERFORMED (Name and Signature)
and Clinical Instructor
(Not applicable for Birthing/Lying-In ASSISTED DELIVERY (If Midwife on Duty,
Time Started (Name and Signature)
Clinics/Homes) Signature not Required)
Noted by: Approved by:
JENNIFER C. PADUAL, MAN, RN____________________ MOIRA G. UY, MAN, RN_____________________________
Signature over printed name of Clinical Coordinator for RLE Signature over printed name of Dean, Department of Nursing
Date Signed: Date Signed: _
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing _
PRC Lic. No.: 0326430 PRC Lic. No.: 0234646 _
Valid Until: August 8, 2024 Valid Until: January 17, 2025 _
PNA No.: M-61209 PNA No.: M-5637 _
Valid Until: December 31, 2023 Valid Until: December 31, 2023 _
