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ACTUAL DELIVERY in__________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student : _________________________________________
DATE
TIME
SUPERVISED BY
Clinical Instructor Name and Signature
Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________
Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________
SURGICAL SCRUB in__________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________
DATE
TIME
SUPERVISED BY
Clinical Instructor Name and Signature
Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________
Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________
SURGICAL SCRUB in__________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________
DATE
TIME
SUPERVISED BY
Clinical Instructor Name and Signature
Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________
Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________
ACTUAL DELIVERY in__________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________
DATE
TIME
PROCEDURE PERFORMED
SUPERVISED BY
Clinical Instructor Name and Signature
Noted by:
Approved by:
( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________
( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________
IMMEDIATE NEWBORN CORD CARE in_____________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________
DATE
TIME
NURSE ON DUTY
( Name and Signature )
SUPERVISED BY
Clinical Instructor Name and Signature
Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________
Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________