ODC Form 1A ACTUAL DELIVERY FORM UNIVERSITY OF ILOILO Rizal St., Iloilo City Tel No. 033-3381071 loc.

127

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

PROCEDURE PERFORMED

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

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC ID No Date document is signed Please specify Highest Nursing Degree Earned Valid Until Time

Approved by: (Print Name and Signature) Dean, PRC I.D. No. Date document is signed Highest Nursing Degree Earned Valid Until Time

ODC Form 1C CORD CARE FORM UNIVERSITY OF ILOILO Rizal St., Iloilo City Tel No., 033-1071 loc. 127

IMMEDIATE NEWBORN CORD CARE 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

Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home

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

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC ID No Date document is signed Please specify Highest Nursing Degree Earned Valid Until Time

Approved by: (Print Name and Signature) Dean, PRC I.D. No. Date document is signed Highest Nursing Degree Earned Valid Until Time

ODC Form 2A O.R. SCRUB FORM MAJOR UNIVERSITY OF ILOILO Rizal St., Iloilo City Tel. No., 033-1071 loc. 127

SURGICAL SCRUB in Hospital/Municipality/City/Province Prepared by: Printed Name and Signature of Student

Date Performed And Time Started

Patients Initial Only Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse on Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC ID No Date document is signed Please specify Highest Nursing Degree Earned Valid Until Time

Approved by: (Print Name and Signature) Dean, PRC I.D. No. Date document is signed Highest Nursing Degree Earned Valid Until Time

ODC Form 2B O.R. CIRCULATING FORM

UNIVERSITY OF ILOILO Rizal St., Iloilo City Tel. No., 033-1071 loc. 127

SURGICAL SCRUB in Hospital,Municipality/City/Province Prepared by: Printed Name and Signature of Student

Date Performed And Time Started

Patients Initial Only Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse on Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC ID No Date document is signed Please specify Highest Nursing Degree Earned Valid Until Time

Approved by: (Print Name and Signature) Dean, PRC I.D. No. Valid Until Date document is signed Time Highest Nursing Degree Earned