U IV R ID DD Z M O N A N ES A E A B A G

Don Toribio St., Tetuan, Zamboanga City, Philippines

Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

ODC Form 1B
ASSISTED DELIVERY FORM

Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 ASSISTED DELIVERY in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari
Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing /Lying In Clinics / Homes)

PROCEDURE PERFORMED

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

(If Midwife on Duty, Signature is not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

May 10,2011 7:58 am

C.M 421654

Normal Spontaneous Vaginal Delivery Aimee Apolinario,RN Madeleine Ruth FelicesAlmonte,RM,RN

Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
PNA I.D. No.______ Date document is signed: Time: Please specify Highest Nursing Degree Earned:

January 24, 2012 Valid Until: ______________ Master in Nursing

Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
PNA I.D. No._______ Valid Until: _____________________ Date document is signed: Time: Specify Highest Nursing Degree Earned: Master in Nursing

U IV R ID DD Z M O N A N ES A E A B A G
Don Toribio St., Tetuan, Zamboanga City, Philippines

ODC Form 1B
ASSISTED DELIVERY FORM

Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 ASSISTED DELIVERY in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari
Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing /Lying In Clinics / Homes)

PROCEDURE PERFORMED

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

(If Midwife on Duty, Signature is not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

May 10, 2011 1:45 pm

C.M 422747

Normal Spontaneous Vaginal Delivery Aimee Apolinario,RN Madeleine Ruth Felices Almonte,RM,RN

Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
PNA I.D. No.________ Date document is signed: Time: Please specify Highest Nursing Degree Earned:

Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976
Valid Until: March 13, 2012 PNA I.D. No. _______ Valid Until: _____________________ Date document is signed: Time: ________ Specify Highest Nursing Degree Earned: Master in Nursing

January 24, 2012___ Valid Until: ___________________ _______ Master in Nursing_____________

U IV R ID DD Z M O N A N ES A E A B A G

ODC Form 1C
CORD CARE FORM

Don Toribio St., Tetuan, Zamboanga City, Philippines

Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 IMMEDIATE NEWBORN CORD CAREin Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari
Date Performed and Time Started Patients INITIALS (only) Case Number

PROCEDURE PERFORMED

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

SUPERVISED BY: Clinical Instructor Name and Signature

May 11,2011 9:25 am

C.S 423304

Immediate Newborn Cord Care

Luzviminda Rugayan,RN,RM

Madeleine Ruth Felices Almonte,RM,RN

Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
PNA I.D. No._______ Date document is signed: ____ Please specify Highest Nursing Degree Earned:

January 24, 2012 Valid Until: ____________________ Time: _______ Master in Nursing

Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
PNA I.D. No. _______ Valid Until: ___________ _ Date document is signed: Time: ____ Specify Highest Nursing Degree Earned: Master in Nursing

U IV R ID DD Z M O N A N ES A E A B A G
Don Toribio St., Tetuan, Zamboanga City, Philippines

ODC Form 2A
D.R. SCRUB FORM Minor

Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari

Date Performed and Time Started

Patients INITIALS Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty

SUPERVISED BY: Clinical Instructor

May 10,2011 10:15 am

E.T 420976

Episiorraphy

Aimee Apolinario,RN

Madeleine Ruth Felices Almonte,RM,RN

Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
PNA I.D. No._____ Date document is signed: Time: Please specify Highest Nursing Degree Earned:

January 24, 2012 Valid Until: ___________________ _______ Master in Nursing

Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
PNA I.D. No. ____________ Valid Until: ____________________ Date document is signed: Time: Specify Highest Nursing Degree Earned: Master in Nursing

U IV R ID DD Z M O N A N ES A E A B A G
Don Toribio St., Tetuan, Zamboanga City, Philippines
Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

ODC Form 1A
ACTUAL DELIVERY FORM

Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 ACTUAL DELIVERY in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

Prepared by: Printed Name with Signature of Student: Misa, Ahmad Edfar Tiamwat
Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing /Lying In Clinics / Homes)

PROCEDURE PERFORMED

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

(If Midwife on Duty, Signature is not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

May 12,2011 7:06 am

L .S .A 435 245

Normal Spontaneous Vaginal Delivery Amor Angelie B. Bazan, RM Ethel Usman,RN,RM

Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
PNA I.D. No._______

January 24, 2012 Valid Until:_____________________ Date document is signed: Time: Please specify Highest Nursing Degree Earned: Master in Nursing

Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
PNA I.D. No. _______ Valid Until:____________ Date document is signed: Time: ________ Specify Highest Nursing Degree Earned: Master in Nursing

U IV R ID DD Z M O N A N ES A E A B A G
Don Toribio St., Tetuan, Zamboanga City, Philippines
Telephone No. (062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

ODC Form 2B
O.R. SCRUB FORM Minor

Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

Prepared by: Printed Name with Signature of Student: ESMAEL, TASNEEM APOSTOL

Date Performed and Time Started

Patients INITIALS Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty

SUPERVISED BY: Clinical Instructor

Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator, PRC I.D. No. 0311858 Valid Until:
PNA I.D. No. 017601 Date document is signed: Please specify Highest Nursing Degree Earned:

January 24, 2012 Valid Until: October 31, 2010 Time: Master in Nursing

Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean, PRC I.D. No. 0205976 Valid Until: March 13, 2012
PNA I.D. No. 017607 Valid Until: October 31, 2010 Date document is signed: Time: Specify Highest Nursing Degree Earned: Master in Nursing