D.

R Form
ACTUAL DELIVERY FORM

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
ACTUAL DELIVERY in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)

PROCEDURE PERFORMED

Case Number
(not applicable for Birthing /Lying In Clinics /
Homes)

Noted by: MA. LOURDES M. WEESIT , R.N., M.N.,

Clinical Coordinator,PRC I.D. No.0102273
Valid Until:
Date document is signed:
Please specify Highest Nursing Degree Earned:

July 18, 2018

Time:
Master in Nursing

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature is not Required)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Approved by: NURSIA M. BARJOSE,R.N., M.N., D.S.N

Dean,PRC I.D. No.0138378 Valid Until: January 29, 2019
Date document is signed:
Specify Highest Nursing Degree Earned:

Time:
Doctor of Science in Nursing

ICND Form
IMMEDIATE CARE OF THE
NEWBORN

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
IMMEDIATE NEWBORN CORD CARE in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number
(not applicable for Birthing /Lying In Clinics /
Homes)

Immediate Newborn Cord Care

PERFORMED

D.R. Nurse On Duty

(Name and Signature)

Indicate where performed e.g. D.R., Nursery,

NICU, or Home

(If Midwife on Duty,

Signature is not Required)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: MA. LOURDES M. WEESIT , R.N., M.N.,

Clinical Coordinator,PRC I.D. No.0102273
Valid Until:

Approved by: NURSIA M. BARJOSE,R.N., M.N., D.S.N

Dean,PRC I.D. No.0138378 Valid Until: January 29, 2019

Date document is signed:

Please specify Highest Nursing Degree Earned:

Date document is signed:

Specify Highest Nursing Degree Earned:

July 18, 2018

Time:
Master in Nursing

Time:
Doctor of Science in Nursing

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

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
SURGICAL SCRUB in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)

SURGICAL PROCEDURE
PERFORMED

Case Number

Noted by: MA. LOURDES M. WEESIT , R.N., M.N.,

Clinical Coordinator,PRC I.D. No.0102273
Valid Until:
Date document is signed:
Please specify Highest Nursing Degree Earned:

July 18, 2018

Time:
Master in Nursing

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Approved by: NURSIA M. BARJOSE,R.N., M.N., D.S.N

Dean,PRC I.D. No.0138378 Valid Until: January 29, 2019
Date document is signed:
Specify Highest Nursing Degree Earned:

Time:
Doctor of Science in Nursing

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

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines

Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
SURGICAL CIRCULATING in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: MA. LOURDES M. WEESIT , R.N., M.N.,

Clinical Coordinator,PRC I.D. No.0102273
Valid Until:

Approved by: NURSIA M. BARJOSE,R.N., M.N., D.S.N

Dean,PRC I.D. No.0138378Valid Until:
January 29, 2019

Date document is signed:

Please specify Highest Nursing Degree Earned:

Date document is signed:

Specify Highest Nursing Degree Earned:

July 18, 2018

Time:
Master in Nursing

Time:
Doctor of Science in Nursing