UNIVERSITY OF SAN CARLOS

COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 MAY 2011
ODC Form 1B ASSISTED DELIVERY FORM

ACTUAL DELIVERY in VICENTE SOTTO MEMORIAL MEDICAL CENTER, CEBU CITY

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

Prepared by: Printed Name with Signature of Student: JUBEL E. LAGBAS

Patients INITIALS (only) Date Performed and Time Started

July 3, 2011 7:15am

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

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature)

(if Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor (Name and Signature)

CRISTINE MARIE F. TORLAO, R.N.,M.A.N.

G.B.J. 260157

ASSISTED DELIVERY

RICHEL P. GOMEZ, R.N.

Noted by: Laarne E. Pontillas, R.N., M.S.N., M.A.N.

(Print Name and Signature)

Approved by: Antonia F. Pascual, R.N., M.N., M.S.N.

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. 0190308 Valid Until June 22, 2011 Date document is signed ______________ Time ________________ Please specify Highest Nursing Degree Earned Master of Science in Nursing Master of Arts in Nursing

DEAN, PRC I.D. No. 0054229 Valid Until August 5, 2012 Date document is signed ______________ Time ________________ Please specify Highest Nursing Degree Earned Master in Nursing Master of Science in Nursing
(STRICTLY NO DESIGNATES)