ODC Form 1A

ACTUAL DELIVERY FORM

CAGAYAN DE ORO COLLEGE

Max Suniel St., Carmen, Cagayan de Oro City
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph

ACTUAL DELIVERY in _________________________________________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student ______________________________________

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

Concurred by: _____________________________________________________ Approved by: ___________________________________________

(Print Name and Signature) (Print Name and Signature)
Chief Nurse, ______ (name of hospital) Dean, PRC I.D. No. __________________ Valid Until ___________
PRC I.D. No. _____________ Valid Until ______________ PNA I.D. No. _____________ Valid Until ______________
PNA I.D. No. _____________ Valid Until ______________ ADPCN I.D. No. _____________ Valid Until ______________
ANSAP I.D. No. _____________ Valid Until ______________ Date document is signed: __________________ Time __________
Date document is signed: _____________________ Time _________________ Please specify Highest Nursing Degree Earned: _______________
Please specify Highest Nursing Degree Earned: _________________________
 ODC Form 1B
ASSISTED DELIVERY
FORM
CAGAYAN DE ORO COLLEGE
Max Suniel St., Carmen, Cagayan de Oro City
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph

ACTUAL DELIVERY in _________________________________________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student ______________________________________

Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse On duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying- Signature not Required)
In Clinics/Homes ASSISTED DELIVERY

Concurred by: _____________________________________________________ Approved by: ___________________________________________

(Print Name and Signature)
Chief Nurse, _____ (name of hospital)
PRC I.D. No. _____________ Valid Until ______________
PNA I.D. No. _____________ Valid Until ______________
ANSAP I.D. No. _____________ Valid Until ______________
Date document is signed: _____________________ Time _________________
Please specify Highest Nursing Degree Earned: _________________________
(Print Name and Signature)
Dean, PRC I.D. No. __________________ Valid Until ___________
PNA I.D. No. _____________ Valid Until ______________
ADPCN I.D. No. _____________ Valid Until ______________
Date document is signed: __________________ Time __________
Please specify Highest Nursing Degree Earned: _______________
 ODC Form 1C
CORD CARE FORM

CAGAYAN DE ORO COLLEGE

Max Suniel St., Carmen, Cagayan de Oro City
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph

IMMEDIATE NEWBORN CORD CARE in ______________________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student ______________________________________

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

Concurred by: _____________________________________________________ Approved by: ___________________________________________

(Print Name and Signature) (Print Name and Signature)
Chief Nurse, ______ (name of hospital) Dean, PRC I.D. No. __________________ Valid Until ___________
PRC I.D. No. _____________ Valid Until ______________ PNA I.D. No. _____________ Valid Until ______________
PNA I.D. No. _____________ Valid Until ______________ ADPCN I.D. No. _____________ Valid Until ______________
ANSAP I.D. No. _____________ Valid Until ______________ Date document is signed: __________________ Time __________
Date document is signed: _____________________ Time _________________ Please specify Highest Nursing Degree Earned: _______________
Please specify Highest Nursing Degree Earned: _________________________
 ODC Form 2A
O.R. SCRUB FORM
Major
CAGAYAN DE ORO COLLEGE
Max Suniel St., Carmen, Cagayan de Oro City
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph

SURGICAL SCRUB in ______________________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student ______________________________________

Date Performed Patient's INITIAL (only) O. R. Nurse On duty SUPERVISED BY

and SURGICAL PROCEDURE (Name AND Signature) Clinical Instructor
Time Started Case Number PERFORMED Name and Signature

Concurred by: _____________________________________________________ Approved by: ___________________________________________

(Print Name and Signature) (Print Name and Signature)
Chief Nurse, ___ (name of hospital) Dean, PRC I.D. No. __________________ Valid Until ___________
PRC I.D. No. _____________ Valid Until ______________ PNA I.D. No. _____________ Valid Until ______________
PNA I.D. No. _____________ Valid Until ______________ ADPCN I.D. No. _____________ Valid Until ______________
ANSAP I.D. No. _____________ Valid Until ______________ Date document is signed: __________________ Time __________
Date document is signed: _____________________ Time _________________ Please specify Highest Nursing Degree Earned: _______________
Please specify Highest Nursing Degree Earned: _________________________
 ODC Form 2B
O.R. CIRCULATING
FORM
CAGAYAN DE ORO COLLEGE
Max Suniel St., Carmen, Cagayan de Oro City
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph

SURGICAL SCRUB in ______________________________________________________________________________

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

Prepared by:
Printed Name and Signature of Student ______________________________________

Date Performed Patient's INITIAL (only) O. R. Nurse On duty SUPERVISED BY

and SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
Time Started Case Number PERFORMED Name and Signature

Concurred by: _____________________________________________________ Approved by: ___________________________________________

(Print Name and Signature)
Chief Nurse, ____ (name of hospital)
PRC I.D. No. _____________ Valid Until ______________
PNA I.D. No. _____________ Valid Until ______________
ANSAP I.D. No. _____________ Valid Until ______________
Date document is signed: _____________________ Time _________________
Please specify Highest Nursing Degree Earned: _________________________
(Print Name and Signature)
Dean, PRC I.D. No. __________________ Valid Until ___________
PNA I.D. No. _____________ Valid Until ______________
ADPCN I.D. No. _____________ Valid Until ______________
Date document is signed: __________________ Time __________
Please specify Highest Nursing Degree Earned: _______________
PRC TEMPLATES OF CASES Signatories
Approved by:

Concurred By: Concurred By:

GEORGE MICHAEL P. LIM, RN, MN MADELEINE C. ZAMAYLA, RN, MAN

Signature over printed Name Signature over printed Name
Chief Nurse - Cagayan de Oro Polymedic Medical Chief
PlazaNurse - Madonna and Child Hospital
Date Signed: Date Signed:
Degree: BSN, RN, MN Degree: BSN, RN, MAN
a) PRC No.: 0380900 a) PRC No.: _________
Valid until: July 17, 2017 Valid until: _____________
b) PNA No.: 1927019685 b) PNA No.
Valid unti Life time Valid until:_______________
c) ANSAP No. 0993 c) ANSAP No._______
Valid until: Life time Valid until: _____________

Concurred By:

LANNIE O. CAPINPUYAN
Signature over printed Name
Chief Nurse - J.R. Borja General Hospital
Date Signed:
Degree: BSN, RN, MAN
a) PRC No.: 0118996
Valid until: October 19, 2017
b) PNA No.:_______
Valid until:_______________
c) ANSAP No. _______

Concurred By:

LORNA P. PADUGANAN ROSITA P. GUTIERREZ, RN, MN

Signature over printed Name Signature over printed Name
OIC Chief Nurse - Northern Mindanao Medical Center Dean, Cagayan de Oro College
Date Signed: Date Signed:
Degree: BSN, RN, MN Degree: BSN, RN, MN
a) PRC No.: 0039297 a) PRC No.: 0173650
Valid until: April 6, 2016 Valid until: January 30, 2019
b) PNA No.: 2014-020639 b) PNA No.:_________
Valid until: December 31, 2014 Valid until: _______________
c) ANSAP No. 13-0725 c) ADPCN No. 14-573
Valid until: December 31, 2014 Valid until: May 31, 2016