Author: ..

PAPRSB INSTITUTE OF HEALTH SCIENCE
UNIVERSITI BRUNEI DARUSSALAM
DIPLOMA IN NURSING
23rd INTAKE (2008—2011 SESSION)
SEMESTER 6
SPECIALITY CLINICAL NURSING PRACTICE
Occupational Health Nursing, Children Nursing and
Peri– Operative Nursing
CLINICAL PLACEMENT ATTENDANCE RECORD

NAME
INDEX NUMBER

INSTRUCTIONS FOR USE
Student must enter time in and time out in the column provided and sign their name at the end of the shift.
The Staff Nurse in-charge or any other qualified staff must verify student’s attendance by printing their initials, name & designation in the column provided and only at the end of the student’s shift.
The permission record needs to be filled in by the student who is requesting to be absent from the clinical placement and should be signed by either the Staff Nurse in-charge or the clinical supervisor.
Attach any medical certificates to the corresponding page.
Any changes in the student’s roster must be negotiated at the latest 2 days before the requested date with the coordinator and the clinical supervisor.
Submit the attendance record to your coordinator / attendance representative at the end of each clinical rotation.
COORDINATOR: Pg Ramlah bte Pg Damit
CO-COORDINATOR: Pg Norasmah bte Pg Hj Ismail
CONTACT NUMBER: 2463001 ext 2203

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward / Clinic : ______________________________
Mentor :_____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Staff / Tutor Initials

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial / Initials

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

Week : _____
Ward : ______________________________
Mentor : _____________________

Date / Duty	Time / In	Time Out	Student’s Signature	Nurse-in charge initial

PERMISSION RECORD

Date	Time In	Time Out	Reason	Nurse-in charge initial

No. of absent days: _______
Remarks:
______________________________________________
______________________________________________

KH@S.DPN6/07/ Revised by noyphi / Aug’09

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