DMC COLLEGE FOUNDATION INC.
Sta. Filomena, Dipolog City, 7100 Philippines
Telefax no: (+63)65-2124029 website: www.dmc.edu.ph email us: collegeofnursing@dmc.edu.ph
Commission on Higher Education, CHED R-IX, Recognition # 00.1.S.1994
ACTUAL DELIVERY in Zamboanga del Norte Medical Center, Corazon C. Aquino Hospital, Dipolog City, Zamboanga Del Norte
Hospital/Home/Lying-in Clinic, Municipality/ City/ Province
Prepared by:
Printed Name and Signature of Student:
Patient INITIAL only DR Nurse On Duty
Date Performed and Case Number (Name and Signature) SUPERVISED BY
Time Started (not applicable for Birthing
PROCEDURE PERFORMED (If Midwife On Duty, Clinical Instructor
Homes/Lying In Clinic/Homes Signature Not Required) (Name and Signature)
Noted by: MARIDOL B. CLARO, R.N., M.N. Approved by: DR. MA. GRACE F. GURDIEL, R.N., M.A.N.
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator,PRC I.D No.0306818 Valid UntilFebruary 21, 2027 Dean, PRC I.D No.0163918 Valid Until November 28, 2027
Date document is signed: _______________________ Time ________________ Date document is signed: ______________________ Time ________________
Please specify Highest Nursing Degree Earned:MASTER IN NURSING Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
(STRICTLY NO DESIGNATES)
ACTUAL DELIVERY FORM
SUBSCRIBE AND SWORN to before this _________________________, at __________________________ City, affiant exhibited to me his/ her C.T.C. No. ____________ issued on
__________________ at ______________________ City, Philippines.
Doc. No. __________
Page No. __________
Book No. __________
Series No. _________
