# 1 Dr. P.V. Larrazabal Jr.

Avenue, North Reclamation 6014 Mandaue City, Cebu, Philippines Phone Number: 238-833 loc 8191-93 Fax Number: 238-8762 Email Address: cdu-cn@cebudoctorsuniversity.edu Website: ww.cebudoctorsuniversity.edu Accreditation Level (if any): LEVEL III PAASCU Year Granted: DECEMBER 2008

Cebu Doctors University COLLEGE OF NURSING

ODC Form 2A O.R. SCRUB FORM Major

SURGICAL SCRUB in
Prepared by: Printed Name and Signature of Student: Date Performed and Time Started Patients INITIAL Only Case Number

Hospital, Municipality/City/Province

SURGICAL PROCEDURE PERFORMED

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

SUPERVISED BY Clinical Instructor Name and Signature

Noted by:

(Print name and Signature) Valid Until: Time:

Approved by: Dean, PRC I.D. No. Date document is signed:

(Print name and Signature) Valid Until: Time:

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

Please specify Highest Nursing Degree Earned: