Lyceum of the Philippines University Capitol Site, Batangas City (043) 723-0706 loc 109-110/www.lyceumbatangas.edu.

ph PACUCOA ACCREDITED, LEVEL III Reaccredited Status, September 2012 September 2017 ACTUAL DELIVERY in Batangas Medical Center/Batangas City/Batangas Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student __Allen E. Cantos____________________________________ Date Performed and Time Started January 4, 2012 9:35am July 16, 2012 12:27pm July 16, 2012 1:45pm Patients INITIAL Only PROCEDURE PERFORMED Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)

DR Form ACTUAL DELIVERY FORM SUPERVISED BY Clinical Instructor Name and Signature

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) Mila A. Engay Mila A. Engay Mila A. Engay

M.J.G. 217176 J.L. 007616 M.P. 012762

Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

Aimee M. Amponin Nerriet F. Lozada Nerriet F. Lozada

IMMEDIATE NEWBORN CORD CARE in Batangas Medical Center/Batangas City/Batangas Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student __Allen E. Cantos____________________________________ Date Performed and Time Started January 5, 2012 8:31am July 16, 2012 11:57am July 18, 2102 11:35am Patients INITIAL Only Case Number
(not applicable for Birthing Homes/Lying-In Clinics/Homes)

ICNB Form IMMEDIATE CARE OF THE NEWBORN FORM SUPERVISED BY

Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home Delivery Room Delivery Room Delivery Room

Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required) Rachelle Laco Mila A. Engay Rowena Aclan

N.J. 436380 M.A. 012640 M.G. 013164

Aimee M. Amponin Nerriet F. Lozada Nerriet F. Lozada

(STRICTLY NO DESIGNATES) (These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)

Lyceum of the Philippines University Capitol Site, Batangas City (043) 723-0706 loc 109-110/www.lyceumbatangas.edu.ph PACUCOA ACCREDITED, LEVEL III Reaccredited Status, September 2012 September 2017 SURGICAL SCRUB in Bauan Doctors General Hospital/Bauan/Batangas Hospital, Municipality/City/Province O.R. Form 1A O.R. SCRUB FORM Major

Prepared by: Printed Name and Signature of Student _Allen E. Cantos______________________________________ Date Performed and Time Started September 24, 2012 6:30pm January 23, 2013 11:10am Patients INITIALS (only) Case Number E.F.M. 0704047 S.T. 0809081009 SURGICAL PROCEDURE PERFORMED Caesarean Section and Bilateral Tubal Ligation Cholecystectomy O.R Nurse On Duty (Name and Signature) Rhodora Abrenica Rhodora Abrenica

SUPERVISED BY Clinical Instructor Name and Signature Ma. Analita L. Bergado Maria Leida O. Garcia

Prepared by: Printed Name and Signature of Student _Allen E. Cantos______________________________________ Date Performed and Time Started September 26, 2012 8:00pm January 22, 2013 12:30pm Patients INITIALS (only) Case Number M.A.C. 0704052 T.N. 0809081006 SURGICAL PROCEDURE PERFORMED Caesarean Section Caesarean Section O.R Nurse On Duty (Name and Signature) Rhodora Abrenica Rhodora Abrenica

O.R. Form 1B O.R. CIRCULATING FORM

SUPERVISED BY Clinical Instructor Name and Signature Ma. Analita L. Bergado Maria Leida O. Garcia

(STRICTLY NO DESIGNATES) (These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)