St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

ODC Form 1A
ACTUAL DELIVERY FORM

Government Recognition No. 012; Series of 1982 July 6, 1981 ACTUAL DELIVERY in Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time of Delivery Patients INITIAL only Case Number
(not applicable for Birthing/ Lyingin Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed:

Valid Until: Time:

Approved by: (Print Name and Signature) Dean, PRC I.D No. Date document is signed:

Valid Until: Time:

St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

Government Recognition No. 012; Series of 1982 July 6, 1981

Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

ODC Form 1B
ASSISTED Delivery FORM

ACTUAL DELIVERY in Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time of Delivery Patients INITIAL only Case Number
(not applicable for Birthing/ Lyingin Clinics/Homes)

PROCEDURE PERFORMED
ASSISTED DELIVERY

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature)

Approved by: (Print Name and Signature)

St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org Valid Until: Time:

Government Recognition No. 012; Series of 1982 July 6, 1981

Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned: Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES) Valid Until:

ODC Time: Form 1C CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time of Delivery Patients INITIAL only Case Number
(not applicable for Birthing/ Lyingin Clinics/Homes)

Immediate Newborn Cord Care PERFORMED

Indicate where performed e.g. D.R., Nursery, NICU, or Home

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

Government Recognition No. 012; Series of 1982 July 6, 1981

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned: Approved by: (Print Name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

Valid Until: Time: O.R. SCRUB FORM Major

ODC Form 2A

SURGICAL SCRUB in Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time Started Patients INITIAL only Case Number O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature

SURGICAL PROCEDURE PERFORMED

St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

Government Recognition No. 012; Series of 1982 July 6, 1981

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until: Time:

Approved by: (Print Name and Signature) Dean, PRC I.D No. Date document is ODC Form 2B signed: Specify Highest Nursing Degree O.R. CIRCULATING FORM Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

SURGICAL SCRUB in Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time Started Patients INITIAL only Case Number O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature

SURGICAL PROCEDURE PERFORMED

St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

Government Recognition No. 012; Series of 1982 July 6, 1981

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D No. Date document is signed: Please specify Highest Nursing Degree Earned:

Valid Until: Time:

Approved by: (Print Name and Signature) Dean, PRC I.D No. Date document is signed: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time: