ODC Form 2

UNIVERSITY OF CAGAYAN VALLEY

ACTUAL DELIVERY FORM
College of Health
College Avenue, Tuguegarao City 3500
Main Campus: Dr. Matias P. Perez Sr. Bldg.
Phone Fax # (078) 844 8981
________________________________________________________________________________________________________________________________________
ACTUAL DELIVERY in ________________________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Name of Student_________________________________________
Date Performed
And
Time Started

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

PROCEDURE PERFORMED

Noted by: __________________________________________________________________

Clinical Coordinator, PRC I.D No. _________________
Valid Until _______________
PNA No. _______________________
Valid Until ___________________________
Date document is signed: _____________________ Time: _________________________
Please specify Highest Nursing Degree Earned: ____________________________________

Signature of Student __________________________________

Nurse/Midwife On Duty
(Name only)

SUPERVISED BY
Clinical Instructor Name and signature

Concurred by: __________________________________________________________________

Chief Nurse, PRC I.D No. ______________________
Valid Until ___________________
PNA No. ___________________________
Valid Until ___________________________
Date document is signed: __________________________ Time: _________________________
Please specify Highest Nursing Degree Earned: _________________________________________

Approved by: ______________________________________________________________

Dean, PRC I.D No. _______________________
Valid Until ___________________________
PNA No. _____________________________
ADPCN No.________________________ Valid Until ___________________________
Date document is signed: _____________________
Please specify Highest Nursing Degree Earned: _________________________________________

Valid Until ____________________

Time: ________________________