EMPLOYMENT FORM

Applicant’s Name: JERICO WENDELL GEE B. RUBIO Date of Birth: 04/11/1997

INSTRUCTIONS
This form must be completed by the director of nursing or midwifery, matron, nurse or midwife manager in the applicant’s
current or previous place of employment. It should not be completed by the applicant. Please include the employer stamp
on the form. When you have completed the form, please provide it to the applicant. We may contact you directly to
clarify and validate the information provided.
Place of Employment Name of Signatory

National Kidney and Transplant Institute Hazel M. Villafranca

Address of Employment Signatory’s Title or Position

East Avenue, Diliman, 1101, Quezon City, Philippines Head Nurse

Signatory’s Email

[email protected]

Organisation Website
Signatory’s Telephone Number
www.nkti.gov.ph
+639177991071

Organisation Email
Date
[email protected]
November 11, 2022

Organisation Stamp
Signature
 Applicant’s Name: Organisation Stamp

JERICO WENDELL GEE B. RUBIO

L E
P
Unit Speciality Title or Role Duties or Responsibilities Competence Level Dates Employed Number of
or Activities in Unit hours per
(DD/MM/YYYY) week
EXAMPLE: Please provide exact title Level 1: Requires constant From DD/MM/YYYY

M
For additional guidance please refer to NMBI Standards and EXAMPLE:
Children’s Ward Requirements supervision and practice to DD/MM/YYYY 40 hours
EXAMPLE: Senior Staff
guidance. Knowledge is weak.
Nurse Paediatrics EXAMPLE: Acts as a clinical role model or leader and mentor for EXAMPLE:
all members of staff. Ensures that each child is assessed, their plan Level 2: Requires occasional 03/11/2005

A
of care implemented, utilising a family centred care approach. supportive guidance and to 15/05/2008
supervision at times.
Provides clinical supervision of junior members of staff, ensures the
Knowledge is developing,
provision of high-quality nursing care to children and their families.

X
understands basic concepts of
Collaborates with colleagues, promotes teamwork, and excellence the skill.
of care. Ensures the application of evidence-based practice.
etc
Monitors stock levels, and effectively engages in the allocation of

E
resources.
Identifies and escalates any life-threatening issues, associated
procedures, protocol and policy guidelines.
Demonstrates competence and clinical understanding of the
therapies and medications used within the paediatric setting,
including the administration of intravenous drugs.
Ensures that documentation is completed accurately and within
agreed timescales.
Ensures confidentiality throughout the patient’s stay.
Demonstrates understanding of and correct use and assembly of
required equipment and appropriate cleaning of same.
Actively participates in clinical risk and quality issues at ward level.
 Applicant’s Name: Organisation Stamp

JERICO WENDELL GEE B. RUBIO

Unit Speciality Title or Role Duties or Responsibilities Competence Level Dates Employed Number of
or Activities in Unit hours per
(DD/MM/YYYY) week

Medical- Staff Nurse Assessing, planning, implementing, and evaluating Stage 3: Competent 05/02/2022 - 40 Hours
Surgical Ward patient care plans in consultation with healthcare Able to provide present
professionals independent care and
assumes greater
Evaluating medical information, as well as providing responsibility
direct and individualized bedside nursing care to pre (From benner's
and post-surgery patients competency level)

Preparing, administering, and recording prescribed

medications

Monitor patients vitals and report adverse reactions to

medications in a timely manner

Answer questions and educate patients and their

families on surgical procedures and post-surgery care

Maintain and update patient files, medical charts, and

health records
 Applicant’s Name: Organisation Stamp

JERICO WENDELL GEE B. RUBIO

Unit Speciality Title or Role Duties or Responsibilities Competence Level Dates Employed Number of
or Activities in Unit hours per
(DD/MM/YYYY) week

Intensive Staff Nurse Monitor exact, detailed reports and records of the Stage 4: Proficient 09/01/2021 - 40 hours
Care Unit critical ICU patients. Perceives situation as a 05/01/2022
contectual whole and
Monitor and record symptoms and changes in recognizes most
patients conditions and information to the physician. significant aspect of the
situation. Performs with
Order, interpret and evaluate diagnostics tests to flexibility.
identify and assess the patient's condition. (From benner's
competency level)
Carefully observe and document patient medical
information and vital signs.

Document patients medical histories and assessment

findings.

Document patients treatment plans, interventions,

outcomes, or plan revisions.
 Applicant’s Name: Organisation Stamp

JERICO WENDELL GEE B. RUBIO

Unit Speciality Title or Role Duties or Responsibilities Competence Level Dates Employed Number of
or Activities in Unit hours per
(DD/MM/YYYY) week

Intensive Staff Nurse Consult and coordinate with health care team Stage 4: Proficient 09/01/2021 - 40 hours
Care Unit members about whole patient care plans. Perceives situation as a 05/01/2022
contectual whole and
Modify patient treatment plans as indicated by recognizes most
patient's response and conditions. significant aspect of the
situation. Performs with
Monitor the critical patients for changes in status and flexibility.
indications of conditions such as sepsis or shock and (From benner's
institute appropriate interventions. competency level)

Administering intravenous fluids and medications as

per doctor's order.

Monitor patients fluid intake and output to detect

emerging problems such as fluid and electrolyte
imbalances.

Identify patients who are at risk of complications due

to nutritional status.
 Applicant’s Name: Organisation Stamp

JERICO WENDELL GEE B. RUBIO

Unit Speciality Title or Role Duties or Responsibilities Competence Level Dates Employed Number of
or Activities in Unit hours per
(DD/MM/YYYY) week

Medical - Staff Nurse Adhere to best nursing practices, standards, and Stage 3: Competent 05/02/2022 - 40 hours
Surgical protocols Able to provide present
Ward independent care and
Changing dressings, inserting catheters, and starting assumes greater
IVs. responsibility
(From benner's
Adjusting specialized medical equipment as needed, competency level)
as well as interpreting and recording measurements