Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Telefax No. (077) 722-7198

ODC Form 1B
ASSISTED DELIVERY
FORM

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

ASSISTED DELIVERY IN GABRIELA SILANG GENERAL HOSPITAL, VIGAN CITY ILOCOS SUR
Hospital/Home/Lying-in-Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student JEREMIASH NOBLESALA DELA CRUZ

Date
Performed
and
Time
Started
06/17/2013
2:00 PM
12/23/2013
10:00 AM
10/28/2013
8:43 AM

Patients INITIAL Only

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

VMT
08056525
JAA
08028081
FSC
08064940

D.R. Nurse On Duty

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

SUPERVISED BY
Clinical Instructor
Name and Signature

Normal Spontaneous Delivery

Ma. Corazon Galinato, RN

Adora M. Velasco, MAN

Normal Spontaneous Delivery

Ma. Corazon Galinato, RN

Adora M. Velasco, MAN

Normal Spontaneous Delivery

Ma. Corazon Galinato, RN

Adora M. Velasco, MAN

PROCEDURE PERFORMED
ASSITED DELIVERY

Noted by: MARIA YOLANDA R. AQUINO

Approved by: LARGUITA P. REOTUTAR

(Printed Name and Signature)

Clinical Coordinator,

PRC I.D. No.: 0257275 Valid Until: March 15, 2015

Date Document is Signed: _____________________ Time: ____________________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

(Printed Name and Signature)

Dean,

PRC I.D. No.: 0078616 Valid Until: August 8. 2015

Date Document is Signed: ______________________ Time: ______________________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

(STRICTLY NO DESIGNATES)

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Telefax No. (077) 722-7198

ODC Form 1C
CORD CARE FORM

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

IMMEDIATE NEWBORN CORD CARE IN GABRIELA SILANG GENERAL HOSPITAL, VIGAN CITY ILOCOS SUR
Hospital/Home/Lying-in-Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student JEREMIASH NOBLESALA DELA CRUZ

Date
Performed
and
Time
Started
2/24/2014
12:02 PM
09/30/2012
9:16 AM
2/20/2014
1:48 PM

Patients INITIAL
Only
Case Number

IMMEDIATE NEWBORN
CORD CARE PERFORMED

Nurse On Duty
(Name and
Signature)

(not applicable for

Birthing/Lying-in-Clinic/Homes)

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

(If Midwife on Duty, Signature

Not Required)

BBQ
08064962
BBR
08044157
BBP
08001707

IMMEDIATE NEWBORN CORD CARE

PERFORMED IN DELIVERY ROOM

Charmaine A. Luis,
RN
Charmaine A. Luis,
RN
Charmaine A. Luis,
RN

IMMEDIATE NEWBORN CORD CARE

PERFORMED IN DELIVERY ROOM
IMMEDIATE NEWBORN CORD CARE
PERFORMED IN DELIVERY ROOM

Noted by: MARIA YOLANDA R. AQUINO

PRC I.D. No.: 0257275 Valid Until: March 15, 2015
Date Document is Signed: _____________________ Time: ____________________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Adora M. Velasco, MAN

Adora M. Velasco, MAN
Adora M. Velasco, MAN

Approved by: LARGUITA P. REOTUTAR

(Printed Name and Signature)

Clinical Coordinator,

SUPERVISED BY
Clinical Instructor
Name and Signature

(Printed Name and Signature)

Dean,

PRC I.D. No.: 0078616 Valid Until: August 8. 2015

Date Document is Signed: ______________________ Time: ______________________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

(STRICTLY NO DESIGNATES)

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Telefax No. (077) 722-7198

ODC Form 1A
ACTUAL DELIVERY
FORM

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

ACTUAL DELIVERY IN CENTRAL ILOCOS SUR DISTRICT HOSPITAL, NARVACAN ILOCOS SUR
Hospital/Home/Lying-in-Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student JEREMIASH NOBLESALA DELA CRUZ

Date
Performed
and
Time
Started
1/8/2014
10:00 AM

Patients INITIAL Only

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

PROCEDURE PERFORMED

D.R. Nurse On Duty

(Name and Signature)

MCO
122430

Normal Spontaneous Delivery

Jerry C. Cabanit, RN

(If Midwife on Duty, Signature Not

Required)

Noted by: MARIA YOLANDA R. AQUINO

PRC I.D. No.: 0257275 Valid Until: March 15, 2015
Date Document is Signed: _____________________ Time: ____________________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Leila Sylvia F. Bautista,

MAN

Approved by: LARGUITA P. REOTUTAR

(Printed Name and Signature)

Clinical Coordinator,

SUPERVISED BY
Clinical Instructor
Name and Signature

(Printed Name and Signature)

Dean,

PRC I.D. No.: 0078616 Valid Until: August 8. 2015

Date Document is Signed: ______________________ Time: ______________________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

(STRICTLY NO DESIGNATES)