SAN PEDRO COLLEGE

12 C. Guzman St., 8000 Davao City

Telephone #: 224-1481; 221-0634; 221-0257 Fax: 226-4461
ACCREDITED: PAASCU - ______________

ODC Form 1A
ACTUAL 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 Started

Patients INITIAL only

Case Number
(not applicable for Birthing/Lying-In
Clinics/Homes)

Noted by: ____________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D No. _____________ Valid Until ___________
Date Document is signed ______________________ Time _______________
Please specify Highest Nursing Degree Earned: _________________________

S
U
P
E
R
V

PROCEDURE
PERFORMED

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ______________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. _______________________ Valid Until _____________
Date Document is signed ______________________ Time _______________
Specify Highest Nursing Degree Earned: _______________________________

ODC Form
1A Form
ODC1A
Form 1A
ODC

ODC
FormDELIVERY
1A
ACTUAL DELIVERY
FORM
ACTUAL
FORM
ACTUAL
DELIVERY
ODC
FormFORM
1A
ACTUAL
DELIVERY
FORM
ACTUAL DELIVERY FORM

I
S
E
D
B
Y
O
.
R
.
N
u
r
s
e
O
n
D
u
t
y
P
a
t
i
e
n
t

s
I

N
I
T
I
A
L
o
n
l
y
S
U
R
G
I
C
A
L
P
R
O
C
E
D
U
R
E

C
l
i
n
i
c
a
l
I
n

s
t
r
u
c
t
o
r
N
a
m
e
a
n
d
S
i
g
n
a
t
u
r
e
(
N
a
m
e
a
n
d
S
i
g
n

a
t
u
r
e
)
P
E
R
F
O
R
M
E
D

S
A
N
P
E
D
R
O
C
O
L
L
E
G
E
1
2
C
.

ODC Form 2A
O.R. SCRUB FORM
Major

G
u
z
m
a
n
S
t
.
,
8
0
0
0
D
a
v
a
o
C
i
t
y
T
e
l
e
p
h
o
n
e
#
:
2

2
4
1
4
8
1
;
2
2
1
0
6
3
4
;
2
2
1
0
2
5
7
F
a
x
:
2
2
6
4
4
6
1
A
C

C
R
E
D
I
T
E
D
:
P
A
A
S
C
U
_
_
_
_
_
_
_
_
_
_
_
_
S
U
R
G
I
C
A
L
S

C
R
U
B
i
n
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
H
o
s
p
i
t
a
l
,
M
u
n
i
c
i
p
a

l
i
t
y
/
C
i
t
y
/
P
r
o
v
i
n
c
e
P
r
e
p
a
r
e
d
b
y
:
P
r
i
n
t
e
d
N

a
m
e
a
n
d
S
i
g
n
a
t
u
r
e
o
f
S
t
u
d
e
n
t
_
_
_
_
_
_
_
_
_
_
_
_
_
_

_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_

D
a
t
e
P
e
r
f

o
r
m
e
d
a
n
d
T
i
m
e
S
t
a
r
t
e
d
C
a
s
e

N
u
m

b
e
r

Noted by: ____________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D No. _____________ Valid Until ___________
Date Document is signed ______________________ Time _______________
Please specify Highest Nursing Degree Earned: _________________________

Approved by: ______________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. _______________________ Valid Until _____________
Date Document is signed ______________________ Time _______________
Specify Highest Nursing Degree Earned: _______________________________

SAN PEDRO COLLEGE

12 C. Guzman St., 8000 Davao City
Telephone #: 224-1481; 221-0634; 221-0257 Fax: 226-4461
ACCREDITED: PAASCU - ___________

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 Started

Patients INITIAL only

Case Number
(not applicable for Birthing/Lying-In
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)
Clinical Coordinator, PRC I.D No. _____________ Valid Until ___________
Date Document is signed ______________________ Time _______________
Please specify Highest Nursing Degree Earned: _________________________
SAN
Patients INITIAL only
SURGICAL
PEDRO
COLLEGE
12 C.
Guzman
St., 8000
Davao City
Telephone
#: 2241481; 2210634; 2210257 Fax:
226-4461
ACCREDIT
ED:
PAASCU _________
____

SURGICAL
SCRUB in
_________
_________
_________
_________
_________
_________
______
Hospital,
Municipality
/City/Provin
ce
Prepared
by:
Printed

O.R.
PROCEDURE Nurse
PERFORMED On
Duty
(Name
and
Signatu
re)

Approved by: ______________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. _______________________ Valid Until _____________
Date Document is signed ______________________ Time _______________
Specify Highest Nursing Degree Earned: _______________________________
SUPERVIS
ODC Form
2B Form 1A
ODC
ED BY
O.R. CIRCULATING
ACTUAL DELIVERY FORM
Clinical
FORM
Instructor
Name and
Signature

Name and
Signature
of Student
_________
_________
_________
_________
__

Date
Performe
d
and
Time
Started
Case
Number

Noted by: ____________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D No. _____________ Valid Until ___________
Date Document is signed ______________________ Time _______________
Please specify Highest Nursing Degree Earned: _________________________

Approved by: ______________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. _______________________ Valid Until _____________
Date Document is signed ______________________ Time _______________
Specify Highest Nursing Degree Earned: _______________________________

SAN PEDRO COLLEGE

12 C. Guzman St., 8000 Davao City
Telephone #: 224-1481; 221-0634; 221-0257 Fax: 226-4461
ACCREDITED: PAASCU - ____________
ACTUAL DELIVERY in ____________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ______________________________________

ODC Form 1C
CORD CARE FORM

Date Performed
and
Time Started

Patients INITIAL only

Case Number
(not applicable for Birthing
Homes/Lying-In Clinics/Homes)

Immediate Newborn Cord Care PERFORMED

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

Noted by: ____________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D No. _____________ Valid Until ___________
Date Document is signed ______________________ Time _______________
Please specify Highest Nursing Degree Earned: _________________________

Nurse on Duty
(Name and Signature)
(If Midwife on Duty, signature
not required)

Approved by: ______________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. _______________________ Valid Until _____________
Date Document is signed ______________________ Time _______________
Specify Highest Nursing Degree Earned: _______________________________

SUPERVISED BY
Clinical Instructor
Name and Signature