AKLAN POLYTECHNIC COLLEGE
College of Nursing
Quezon Avenue, Kalibo, Aklan, Philippines
Office No. (036) 268-8698; Fax No. (036) 262-8573
E-mail Add: aklanpolytechnic@gmail.com
IMMEDIATE NEWBORN CORD CARE in Dr. Rafael S. Tumbokon Memorial Hospital, Kalibo, Aklan
Prepared by: ICNB FORM
IMMEDIATE CARE OF THE NEWBORN FORM
Printed Name and Signature of Student: LAYSON, John Lourd Panaguiton
IMMEDIATE CARE OF THE NEWBORN FORM
Date Performed Patient’s Initial Name and Signature SUPERVISED BY:
No. and Immediate Newborn Cord Care PERFORMED of Clinical Instructor
Time Started D.R. Nurse on Duty Name and Signature
Case Number
Baby Girl Z.
1 09-27-24/01:19 A.M. Delivery Room
515483 Fritzie Lee T. Romulo, RN Donita M. Sixon, MANu, RN/Rommel M. Bana-ay, MAN, RN
Supervised by: Noted by: Approved by:
ROMMEL M. BANA-AY, MAN, RN RUTH T. ANDAYA, MAN, RN ELVIE A. IMASON, MAN, RN
Signature over printed name of Supervising Nurse Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Date Signed: October 9, 2024 Date Signed: October 10, 2024 Date Signed: October 11, 2024
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing
a) PRC No.: 0436158 a) PRC No.: 0185997 a) PRC No.: 0271364
Valid until: September 28, 2027 Valid until: December 10, 2025 Valid until: March 25, 2025
b) PNA No.: M-36252 b) PNA No.: M-32022 b) PNA No.: M-31451
Valid until: December 31, 2024 Valid until: December 31, 2025 Valid until: December 31, 2024
AKLAN POLYTECHNIC COLLEGE
College of Nursing
Quezon Avenue, Kalibo, Aklan, Philippines
Office No. (036) 268-8698; Fax No. (036) 262-8573
E-mail Add: aklanpolytechnic@gmail.com
IMMEDIATE NEWBORN CORD CARE in Dr. Rafael S. Tumbokon Memorial Hospital, Kalibo, Aklan
Prepared by:
ICNB FORM
IMMEDIATE CARE OF THE NEWBORN FORM
Printed Name and Signature of Student: LAYSON, John Lourd Panaguiton
IMMEDIATE CARE OF THE NEWBORN FORM
Date Performed Patient’s Initial Name and Signature SUPERVISED BY:
No. and Immediate Newborn Cord Care PERFORMED of Clinical Instructor
Time Started D.R. Nurse on Duty Name and Signature
Case Number
Baby Boy B.
2 02-28-25/03:28 A.M. Delivery Room
516869 Roanne U. Hilario, RN Donita M. Sixon, MANu, RN/Rommel M. Bana-ay, MAN, RN
Supervised by: Noted by: Approved by:
ROMMEL M. BANA-AY, MAN, RN RUTH T. ANDAYA, MAN, RN ELVIE A. IMASON, MAN, RN
Signature over printed name of Supervising Nurse Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Date Signed: March 26, 2025 Date Signed: March 27, 2025 Date Signed: March 28, 2025
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing
a) PRC No.: 0436158 a) PRC No.: 0185997 a) PRC No.: 0271364
Valid until: September 28, 2027 Valid until: December 10, 2025 Valid until: March 25, 2028
b) PNA No.: M-36252 b) PNA No.: M-32022 b) PNA No.: M-31451
Valid until: December 31, 2025 Valid until: December 31, 2025 Valid until: December 31, 2025
AKLAN POLYTECHNIC COLLEGE
College of Nursing
Quezon Avenue, Kalibo, Aklan, Philippines
Office No. (036) 268-8698; Fax No. (036) 262-8573
E-mail Add: aklanpolytechnic@gmail.com
IMMEDIATE NEWBORN CORD CARE in Dr. Rafael S. Tumbokon Memorial Hospital, Kalibo, Aklan
‘
Prepared by:
ICNB FORM
IMMEDIATE CARE OF THE NEWBORN FORM
Printed Name and Signature of Student: LAYSON, John Lourd Panaguiton
IMMEDIATE CARE OF THE NEWBORN FORM
Date Performed Patient’s Initial Name and Signature SUPERVISED BY:
No. and Immediate Newborn Cord Care PERFORMED of Clinical Instructor
Time Started D.R. Nurse on Duty Name and Signature
Case Number
Baby Girl C.
3 03-14-25/01:24 A.M. Delivery Room
516971 Roanne U. Hilario, RN Donita M. Sixon, MANu, RN/Rommel M. Bana-ay, MAN, RN
Supervised by: Noted by: Approved by:
ROMMEL M. BANA-AY, MAN, RN RUTH T. ANDAYA, MAN, RN ELVIE A. IMASON, MAN, RN
Signature over printed name of Supervising Nurse Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Date Signed: March 26, 2025 Date Signed: March 27, 2025 Date Signed: March 28, 2025
Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing Degree: Master of Arts in Nursing
a) PRC No.: 0436158 a) PRC No.: 0185997 a) PRC No.: 0271364
Valid until: September 28, 2027 Valid until: December 10, 2025 Valid until: March 25, 2028
b) PNA No.: M-36252 b) PNA No.: M-32022 b) PNA No.: M-31451
Valid until: December 31, 2025 Valid until: December 31, 2025 Valid until: December 31, 2025
