ODC Form 1A

ACTUAL DELIVERY
FORM

UNIVERSIDAD DE MANILA
(formerly City College of Manila)
Palma St Cor Arroceros St Mehan Gardens, Manila

ACTUAL DELIVERY in ___________________________________________

Hospital/Home/ Lying-in Clinic/Municipality/City/Province

Prepared by: ___________________________________

Patient’s INITIAL Only

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

Noted by:_______________________________ Approved by: __________________________________ ______

Clinical Coordinator, PRC I.D. No. ___________ Valid Until ____________ Dean, PRC I.D. No. _______________ Valid Until __________
Date: ___________________Time ___________________ Date: __________ Time: ________________
Highest Nursing Degree Earned: _____________________ Highest Nursing Degree Earned: __________________

(STRICTLY NO DESIGNATES)
 ODC Form 1C
O.R. SCRUB FORM
Major

UNIVERSIDAD DE MANILA
(formerly City College of Manila)
Palma St Cor Arroceros St Mehan Gardens, Manila

SURGICAL SCRUB in _______________________________

Hospital, Municipality/City/Province

Prepared by: ___________________________________

Patient’s INITIAL Only

Date Performed SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse On Duty
and Case Number Clinical Instructor
PERFORMED (Name and Signature)
Time Started Name and Signature

Noted by:_______________________________ Approved by: __________________________________ ______

Clinical Coordinator, PRC I.D. No. ___________ Valid Until ____________ Dean, PRC I.D. No. _______________ Valid Until __________
Date: ___________________Time __________________ Date: __________ Time: ______________
Highest Nursing Degree Earned: _____________________ Highest Nursing Degree Earned: __________________

(STRICTLY NO DESIGNATES)
 ODC Form 1B
ASSISTED DELIVERY
FORM

UNIVERSIDAD DE MANILA
(formerly City College of Manila)
Palma St Cor Arroceros St Mehan Gardens, Manila

ACTUAL DELIVERY in ___________________________________________

Hospital/Home/ Lying-in Clinic/Municipality/City/Province

Prepared by: ___________________________________

Patient’s INITIAL Only

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

Noted by:_______________________________ Approved by: __________________________________ ______

Clinical Coordinator, PRC I.D. No. ___________ Valid Until ____________ Dean, PRC I.D. No. _______________ Valid Until __________
Date: ___________________Time _______________ Date: __________ Time: ______________
Highest Nursing Degree Earned: _____________________ Highest Nursing Degree Earned: __________________

(STRICTLY NO DESIGNATES)
 ODC Form 2B
O.R. CIRCULATING
FORM

UNIVERSIDAD DE MANILA
(formerly City College of Manila)
Palma St Cor Arroceros St Mehan Gardens, Manila

SURGICAL SCRUB in _______________________________

Hospital, Municipality/City/Province

Prepared by: ___________________________________

Patient’s INITIAL Only

Date Performed SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse On Duty
and Case Number Clinical Instructor
PERFORMED (Name and Signature)
Time Started Name and Signature

Noted by:_______________________________ Approved by: __________________________________ ______

Clinical Coordinator, PRC I.D. No. ___________ Valid Until ____________ Dean, PRC I.D. No. _______________ Valid Until __________
Date: ___________________Time _______________ Date: __________ Time: ______________
Highest Nursing Degree Earned: _____________________ Nursing Degree Earned: __________________

(STRICTLY NO DESIGNATES)
 ODC Form 1C
CORD CARE FORM

UNIVERSIDAD DE MANILA
(formerly City College of Manila)
Palma St Cor Arroceros St Mehan Gardens, Manila

IMMEDIATE NEWBORN CORD CARE in _____________________________________

Hospital/Home/ Lying-in Clinic/Municipality/City/Province

Prepared by: ___________________________________

Patient’s INITIAL Only

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

Noted by:_______________________________ Approved by: __________________________________ ______

Clinical Coordinator, PRC I.D. No. ___________ Valid Until ____________ Dean, PRC I.D. No. _______________ Valid Until __________
Date: ___________________Time _______________ Date: __________ Time: ______________
Highest Nursing Degree Earned: ____________________ Highest Nursing Degree Earned: __________________

(STRICTLY NO DESIGNATES)