Republic of the Philippines

DR Form 1A
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY ACTUAL DELIVERY FORM
Cabanatuan City
ISO 9001:2015 Certified
COLLEGE OF NURSING

Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
Level : _LEVEL 3 PHASE 2
Date of Accreditation: DECEMBER 8, 2020

ACTUAL DELIVERY in: _ GAPAN DISTRICT HOSPITAL, GAPAN CITY, NUEVA ECIJA__ _
Hospital/Municipal/City/Province
Prepared by:

Name of Student:____TAMAYO, KAREN GRACE A. _ _

Printed Name & Signature of Student

Date Performed Patient’s INITIAL SUPERVISED BY:

only PROCEDURE PERFORMED Nurse on Duty
and
(ACTUAL DELIVERY) Clinical Instructor
Time started Case Number
01/25/24 S.M.V.P.
Normal Spontaneous Delivery - Boy
4:10 PM 672906
Leonora M. Lagamia, MAN, RN Leonora M. Lagamia, MAN, RN
01/26/24 A.G.N. Normal Spontaneous Delivery
6:15 PM 673357 with Repair - Boy
Leonora M. Lagamia, MAN, RN Leonora M. Lagamia, MAN, RN

Noted by: Approved by:

KRISTHINE ABEGAIL M. GAMIAO, MAN, RN DR. JEAN N. GUILLASPER, RN

RLE UNIT HEAD DEAN
PRC ID. No. : 0404082 Valid until: 01/05/2026 PRC ID. No. :0319621 Valid until: 11/15/2024
PNA No. : M-15419 Valid until: 12/31/2025 PNA No. :18617 Valid until: Lifetime
Highest Degree Earned: Master of Arts in Nursing ADPCN ID. No.: 16-677 Valid until: 2025
Date signed: ____________________ Highest Degree Earned: Doctor of Philosophy
Date signed:_____________________