TARLAC STATE UNIVERSITY ODC FORM 2

ROMULO BLVD. SAN VICENTE, TARLAC CITY ACTUAL DELIVERY FORM

(045)493-1865/ Telefax. (045) 982-0110/ www.tsu.edu.ph

ACTUAL DELIVERY in Tarlac Provincial Hospital, Tarlac City

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Students ____________________________ Signature of Student________________________

Patient Name
D.R. Nurse/Midwife SUPERVISED BY
Date Performed Case Number PROCEDURE PERFORMED On Duty Clinical Instructor
And Time Started (not applicable for (Name only) Name and Signature
Birthing/Lying-In
Clinics/Homes)

Concurred by: Approved by: Noted by:

ERLINDA S. LAGONILLA PROF. LUCILA O. SUNGA APOLLO G. FACUN

(Signature over printed name of Chief Nurse) (Signature over printed name of Dean) (Signature over printed name of Chairman, RLE Instruction)
Date Signed: ____________________ Date Signed: _______________________ Date Signed: ______________________
Degree: RN, RM, MSN____________ Degree: RN, MPA, MAN______________ Degree: RN, MSN__________________
PRC No. 46196__________________ PRC No. 0135647___________________ PRC No. 0207378__________________
Valid Until: February 2011_________ Valid Until: September 2010___________ Valid Until: December 2013__________
PNA No. 2410 _________________ PNA No. 539620 __________________ PNA No. 056495_ _________________
Valid Until: Lifetime_______________ Valid Until: Lifetime__________________ Valid Until: October 2010___________
ANSAP No. 0106__________________ ADCPN No: 535_ ____________________
Valid Until: Lifetime _______________ Valid Until: December_2010__________
 TARLAC STATE UNIVERSITY ODC FORM 3
ROMULO BLVD. SAN VICENTE, TARLAC CITY D.R. ASSIST FORM
(045)493-1865/ Telefax. (045) 982-0110/ www.tsu.edu.ph

ACTUAL DELIVERY in Tarlac Provincial Hospital, Tarlac City and Concepcion District Hospital, Concepcion, Tarlac
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Students ____________________________ Signature of Student________________________

Patient Name
D.R. Nurse/Midwife SUPERVISED BY
Date Performed Case Number PROCEDURE PERFORMED On Duty Clinical Instructor
And Time Started (not applicable for (Name only) Name and Signature
Birthing/Lying-In
Clinics/Homes)

Concurred by: Approved by: Noted by:

ERLINDA S. LAGONILLA PROF. LUCILA O. SUNGA APOLLO G. FACUN

(Signature over printed name of Chief Nurse) (Signature over printed name of Dean) (Signature over printed name of Chairman, RLE Instruction)
Date Signed: ____________________ Date Signed: _______________________ Date Signed: ______________________
Degree: RN, RM, MSN____________ Degree: RN, MPA, MAN______________ Degree: RN, MSN__________________
PRC No. 46196__________________ PRC No. 0135647___________________ PRC No. 0207378__________________
Valid Until: February 2011_________ Valid Until: September 2010___________ Valid Until: December 2013__________
PNA No. 2410 _________________ PNA No. 539620 __________________ PNA No. 056495_ _________________
Valid Until: Lifetime_______________ Valid Until: Lifetime__________________ Valid Until: October 2010___________
ANSAP No. 0106__________________ ADCPN No: 535_ ____________________
Valid Until: Lifetime _______________ Valid Until: December_2010__________
 TARLAC STATE UNIVERSITY ODC FORM 4
ROMULO BLVD. SAN VICENTE, TARLAC CITY D.R. IMMEDIATE NEWBORN
CORD CARE FORM
(045)493-1865/ Telefax. (045) 982-0110/ www.tsu.edu.ph

ACTUAL DELIVERY in Tarlac Provincial Hospital, Tarlac City and Concepcion District Hospital, Concepcion, Tarlac
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Students ____________________________ Signature of Student________________________

Patient Name
Immediate Newborn Cord Care
D.R. Nurse/Midwife SUPERVISED BY
Date Performed Case Number PERFORMED
On Duty Clinical Instructor
And Time Started (not applicable for Indicate where performed e.g. D.R.,
(Name only) Name and Signature
Birthing/Lying-In Nursery, NICU, or Home
Clinics/Homes)

Concurred by: Approved by: Noted by:

ERLINDA S. LAGONILLA PROF. LUCILA O. SUNGA APOLLO G. FACUN

(Signature over printed name of Chief Nurse) (Signature over printed name of Dean) (Signature over printed name of Chairman, RLE Instruction)
Date Signed: ____________________ Date Signed: _______________________ Date Signed: ______________________
Degree: RN, RM, MSN____________ Degree: RN, MPA, MAN______________ Degree: RN, MSN__________________
PRC No. 46196__________________ PRC No. 0135647___________________ PRC No. 0207378__________________
Valid Until: February 2011_________ Valid Until: September 2010___________ Valid Until: December 2013__________
PNA No. 2410 _________________ PNA No. 539620 __________________ PNA No. 056495_ _________________
Valid Until: Lifetime_______________ Valid Until: Lifetime__________________ Valid Until: October 2010___________
ANSAP No. 0106__________________ ADCPN No: 535_ ____________________
Valid Until: Lifetime _______________ Valid Until: December_2010__________
 TARLAC STATE UNIVERSITY ODC FORM 1
ROMULO BLVD. SAN VICENTE, TARLAC CITY O.R. SCRUB FORM
(045)493-1865/ Telefax. (045) 982-0110/ www.tsu.edu.ph Major

SURGICAL SCRUB in Tarlac Provincial Hospital, Tarlac City and Talon General Hospital, Tarlac City
Hospital, Municipality/City/Province

Prepared by:
Name of Students ____________________________ Signature of Student________________________

Patient Name SUPERVISED BY

Date Performed O.R. Nurse On Duty
PROCEDURE PERFORMED Clinical Instructor
And Time Started (Name only)
Case Number Name and Signature

Concurred by: Approved by: Noted by:

ERLINDA S. LAGONILLA PROF. LUCILA O. SUNGA APOLLO G. FACUN

(Signature over printed name of Chief Nurse)
Date Signed: ____________________
Degree: RN, RM, MSN____________
PRC No. 46196__________________
Valid Until: February 2011_________
PNA No. 2410 _________________
Valid Until: Lifetime_______________
ANSAP No. 0106__________________
Valid Until: Lifetime _______________
(Signature over printed name of Dean)
Date Signed: _______________________
Degree: RN, MPA, MAN______________
PRC No. 0135647___________________
Valid Until: September 2010___________
PNA No. 539620 __________________
Valid Until: Lifetime__________________
ADCPN No: 535_ ____________________
Valid Until: December_2010__________
(Signature over printed name of Chairman, RLE Instruction)
Date Signed: ______________________
Degree: RN, MSN__________________
PRC No. 0207378__________________
Valid Until: December 2013__________
PNA No. 056495_ _________________
Valid Until: October 2010___________
 TARLAC STATE UNIVERSITY ODC FORM 1
ROMULO BLVD. SAN VICENTE, TARLAC CITY O.R. SCRUB FORM
(045)493-1865/ Telefax. (045) 982-0110/ www.tsu.edu.ph Minor

SURGICAL SCRUB in Tarlac Provincial Hospital, Tarlac City

Hospital, Municipality/City/Province

Prepared by:
Name of Students ____________________________ Signature of Student________________________

Patient Name SUPERVISED BY

Date Performed O.R. Nurse On Duty
PROCEDURE PERFORMED Clinical Instructor
And Time Started (Name only)
Case Number Name and Signature

Concurred by: Approved by: Noted by:

ERLINDA S. LAGONILLA PROF. LUCILA O. SUNGA APOLLO G. FACUN

(Signature over printed name of Chief Nurse) (Signature over printed name of Dean) (Signature over printed name of Chairman, RLE Instruction)
Date Signed: ____________________ Date Signed: _______________________ Date Signed: ______________________
Degree: RN, RM, MSN____________ Degree: RN, MPA, MAN______________ Degree: RN, MSN__________________
PRC No. 46196__________________ PRC No. 0135647___________________ PRC No. 0207378__________________
Valid Until: February 2011_________ Valid Until: September 2010___________ Valid Until: December 2013__________
PNA No. 2410 _________________ PNA No. 539620 __________________ PNA No. 056495_ _________________
Valid Until: Lifetime_______________ Valid Until: Lifetime__________________ Valid Until: October 2010___________
ANSAP No. 0106__________________ ADCPN No: 535_ ____________________
Valid Until: Lifetime _______________ Valid Until: December_2010__________