Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
San Miguel Nabua, Camarines Sur
CSPC-F-COL(CHS)-53
Tel./Fax No.: (054) 288-4421-23
Website: www.cspc.edu.ph Email: chs@cspc.edu.ph
AACCUP Accredited Level III Re-Accredited, October 1, 2016-September 30, 2020
ACTUAL DELIVERY in ________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
DR Form
ACTUAL DELIVERY FORM
Prepared by: __ ___________________________ __

Patient’s INITIAL Only

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

IMMEDIATE NEWBORN CORD CARE in ________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province ICNB Form
IMMEDIATE CARE OF THE
Prepared by: __ ____________________________ __ NEWBORN Form

Patient’s INITIAL Only

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

SUBSCRIBED AND SWORN to before me this day of 2021 at Nabua, Camarines Sur, Philippines