ODC Form

2A O.R.
SCRUB FORM
Major
JOSE RIZAL UNIVERSITY
80 Shaw Boulevard, Mandaluyong City
Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu
www.jru.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

Date Patient’s INITIALS O.R. Nurse On SUPERVISED

Performed (only) SURGICAL Duty BY
and Case Number Clinical
Time
PROCEDURE (Name AND
Instructor
Started PERFORMED Signature) Name and

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO
DESIGNATES)
 ODC Form 2B
O.R. MINOR FORM

JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City
Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu
www.jru.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student

Date Patient’s INITIALS O.R. Nurse On SUPERVISED

Performed Only SURGICAL Duty BY
and Case Number Clinical
Time
PROCEDURE (Name and
Instructor
Started PERFORME Signature) Name and

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO
DESIGNATES)
 ODC 1A
Form ACTUAL DELIVERY
FORM

JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City
Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu
www.jru.edu.ph

ACTUAL DELIVERY in
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student

Date Patient’s INITIAL PROCEDU D.R. Nurse On SUPERVISED

Performed Only RE Duty BY
an Case Number (Name and Clinical
d (not applicable for PERFORME Instructor
Signature) (If
Time Birthing/Lying- In D Midwife on Duty,
Name and
Started Clinics/Homes) Signature
Signature Not

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO
DESIGNATES)
 ODC Form 1B
ASSISTED
DELIVERY FORM
JOSE RIZAL UNIVERSITY
80 Shaw Boulevard, Mandaluyong
City
Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu
www.jru.edu.ph

ACTUAL DELIVERY in

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student

Date Patient’s INITIAL PROCEDU D.R. Nurse On SUPERVISED

Performed Only RE Duty BY
an Case Number (Name and Clinical
d (not applicable for PERFORME Signature) (If Instructor
Time Birthing/Lying- In D Midwife on Duty, Name and
Started Clinics/Homes) Signature Not Signature
Required)

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO
DESIGNATES)
 ODC Form
1C
CORD CARE
FORM

JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City
Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu
www.jru.edu.ph

IMMEDIATE NEWBORN CORD CARE in

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student

Date Patient’s INITIAL Immediate Newborn Cord Nurse On SUPERVISED

Performed Only Care Duty BY
Case Number
an (not applicable for PERFORME (Name and Clinical
d Birthing D Signature) (If Instructor
Time Homes/Lying-In Midwife on Duty, Name and
Indicate where performed
Started Clinics/Homes) signature not Signature
e.g. D.R., Nursery, NICU, or

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO
DESIGNATES)