Saint Francis of Assisi College

ODC Form 1A
ACTUAL DELIVERY
FORM

045 Admiral Village, Talon III, Las Pias City, Metro Manila
Tel. # 800-4507, Tele Fax # 805-8014
Email Add: info@stfrancis@edu.ph, Web site: www.stfrancis.edu.ph
ACTUAL DELIVERY in:

_________________________________________________________________________________________
Hospital, Municipality / City / Province

Prepared by :
____________________________
Name of Student: ________________________________

Date Performed
and
Time Started

Signature of Student :

Patients INITIAL Only

D.R. Nurse On Duty
Case Number

Procedure Performed

(not applicable for Birthing / Lying

in Clinics / Homes)

Noted By: ____________

_______________________
Clinical Coordinator, PRC ID No. ________ Valid Until:
Date document is signed
Time:
Please specify Highest Nursing Degree Earned:

(Name and Signature)

(If Midwife on Duty,
Signature not required)

Supervised By
Clinical Instructor
Name and Signature

Approved By: ___________________________________________

Dean, PRC ID No. ____________ Valid Until: ____________
Date document is signed
Time: ____________
Please specify Highest Nursing Degree Earned: ___________________

Saint Francis of Assisi College

ODC Form 1B
ASSIST DELIVERY
FORM

045 Admiral Village, Talon III, Las Pias City, Metro Manila
Tel. # 800-4507, Tele Fax # 805-8014
Email Add: info@stfrancis@edu.ph, Web site: www.stfrancis.edu.ph
ASSISTED DELIVERY in:

_______________________________________________________________________________________
Hospital, Municipality / City / Province

Prepared by :
Name of Student :

Date Performed
and
Time Started

__________________
____________________

Signature of Student :

Patients INITIAL Only

Case Number

D.R. Nurse On Duty

Procedure Performed

(not applicable for Birthing /

Lying-in Clinics / Homes)

Noted By:
________
_____________________
Clinical Coordinator, PRC ID No. _______ Valid Until: _________________
Date document is signed
_____ Time:
_________

(Name and Signature)

(If Midwife on Duty, Signature
not Required)

Supervised By
Clinical Instructor
Name and Signature

Approved By: ____________________________________________

Dean, PRC ID No_____________ Valid Until: __________________
Date document is signed
Time: ____________

Please specify Highest Nursing Degree Earned:

_______

Please specify Highest Nursing Degree Earned: ____________________

Saint Francis of Assisi College

ODC Form 1C
D.R. IMMEDIATE
NEWBORN

045 Admiral Village, Talon III, Las Pias City, Metro Manila
Tel. # 800-4507, Tele Fax # 805-8014
Email Add: info@stfrancis@edu.ph, Web site: www.stfrancis.edu.ph
IMMEDIATE NEWBORN CORD CARE in:

______________________________________________________________________________
Hospital, Municipality / City / Province

Prepared by :
Name of Student :

Date Performed
and
Time Started

_________________________
_____________________
Patients INITIAL Only
Case Number
(not applicable for Birthing /
Lying-in Clinics / Homes)

Signature of Student :
Immediate Newborn Cord
Care
PERFORMED
(Indicate where performed e.g. D.R.,
Nursery, NICU, or Home)

Noted By:
__________________________________
Clinical Coordinator, PRC ID No. ______ __ Valid Until:
___________
Date document is signed
Time:

D.R. Nurse On Duty

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

Supervised By
Clinical Instructor
Name and Signature

Approved By: ________________________________________ _____

Dean, PRC ID No. __________ Valid Until: ____________________
Date document is signed
Time: ____________

Please specify Highest Nursing Degree Earned:

Please specify Highest Nursing Degree Earned: ____________________

Saint Francis of Assisi College

ODC Form 2A
O.R. SCRUB FORM
MAJOR

045 Admiral Village, Talon III, Las Pias City, Metro Manila
Tel. # 800-4507, Tele Fax # 805-8014
Email Add: info@stfrancis@edu.ph, Web site: www.stfrancis.edu.ph
SURGICAL SCRUB (MAJOR) in:

_____________________________________________________________________________________
Hospital, Municipality / City / Province

Prepared by :
Name of Student :
Date Performed
and
Time Started

________________________
_________________________

Signature of Student :

Patients INITIAL Only

Procedure Performed
Case Number

Noted By:
_____________
______
Clinical Coordinator, PRC ID No. _______ Valid Until: ________________
Date document is signed
Time:
Please specify Highest Nursing Degree Earned:

O.R. Nurse On Duty

Name and SIgnature

Supervised By
Clinical Instructor
Name and Signature

Approved By: ____________________________________________

Dean, PRC ID No. ____________ Valid Until: ___________________
Date document is signed
Time: ____________
Please specify Highest Nursing Degree Earned: ____________________

Saint Francis of Assisi College

ODC Form 2B
O.R. SCRUB FORM
MINOR

045 Admiral Village, Talon III, Las Pias City, Metro Manila
Tel. # 800-4507, Tele Fax # 805-8014
Email Add: info@stfrancis@edu.ph, Web site: www.stfrancis.edu.ph
SURGICAL SCRUB (MINOR) in:

______________________________________________________________________________________
Hospital, Municipality / City / Province

Prepared by :
Name of Student :
Date Performed
and
Time Started

________________________
_______________________

Signature of Student :

Patients Name
Procedure Performed
Case Number

Noted By:
________________________
Clinical Coordinator, PRC ID No. ________ Valid Until:
Date document is signed
Please specify Highest Nursing Degree Earned:

_______
Time:

O.R. Nurse On Duty

Name and SIgnature

Supervised By
Clinical Instructor
Name and Signature

Approved By: ____________________________________________

Dean, PRC ID No. ____________ Valid Until: ______________
Date document is signed
Time: ____________
Please specify Highest Nursing Degree Earned: ___________________