ODC Form 1A
DE LOS SANTOS-STI COLLEGE, INC ACTUAL DELIVERY FORM
201 E. Rodriguez Sr. Blvd., Quezon City
721-78-71/721-78-87/721-7877/ 722-06-27
ACTUAL DELIVERY in Batasan Lying-in Clinic, Batasan Quezon city
Hospital/Home/Lying-In Clinic,Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: Dulay, Bea Kristine S.
Patient's INITIAL (Only)
D.R. Nurse On Duty
Date Performed Case Number SUPERVISED BY
PROCEDURE (Name and Signature)
and (not applicable for Clinical Instructor
PERFORMED (If Midwife on Duty,
Time Started Birthing /Lying- In Name and Signature
Signature not Require)
Clinics/Homes)
July 14, 2009
AMG Normal Spontaneous Delivery
10:42 pm
Ms. Gen Buizon, RM Ms. Wilfrida B. Narciso, RN, MAN
July 21, 2009
CM Normal Spontaneous Delivery
4:34 pm
Ms. Jocelyn Polido, RM Ms. Wilfrida B. Narciso, RN, MAN
(Print Name and Signature) (Print Name and Signature)
Noted by: MR. ROMEO G. SAÑO, R.N., M.A.N Approved by: MS. NORIELEE S. MAGSINGIT, R.N., M.A.N
Clinical Coordinator, PRC I.D No 243835 Valid Until December 7, 2013 Dean, PRC I.D. No 162291 Valid Until April 6, 2011
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: R.N., M.A.N Specify Highest Nursing Degree Earned: R.N., M.A.N
(STRICTLY NO DESIGNATES)
ODC Form 1A
DE LOS SANTOS-STI COLLEGE, INC ACTUAL DELIVERY FORM
201 E. Rodriguez Sr. Blvd., Quezon City
721-78-71/721-78-87/721-7877/ 722-06-27
ACTUAL DELIVERY in Kamuning Lying-in Clinic, Kamuning Quezon city
Hospital/Home/Lying-In Clinic,Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: Dulay, Bea Kristine S.
Patient's INITIAL (Only)
D.R. Nurse On Duty
Date Performed Case Number SUPERVISED BY
PROCEDURE (Name and Signature)
and (not applicable for Clinical Instructor
PERFORMED (If Midwife on Duty,
Time Started Birthing /Lying- In Name and Signature
Signature not Require)
Clinics/Homes)
December 8, 2009
JS Normal Spontaneous Delivery Ms. Zenaida Felix, RM
4:45 pm
Ms. Arlene I. Santella RN, MAN
December 8, 2009
CJ Normal Spontaneous Delivery Ms. Rodina Fernandez, RM
7:06 pm
Ms. Arlene I. Santella RN, MAN
(Print Name and Signature) (Print Name and Signature)
Noted by: MR. ROMEO G. SAÑO, R.N., M.A.N Approved by: MS. NORIELEE S. MAGSINGIT, R.N., M.A.N
Clinical Coordinator, PRC I.D No 243835 Valid Until December 7, 2013 Dean, PRC I.D. No 162291 Valid Until April 6, 2011
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: R.N., M.A.N Specify Highest Nursing Degree Earned: R.N., M.A.N
(STRICTLY NO DESIGNATES)
DE LOS SANTOS-STI COLLEGE, INC
201 E. Rodriguez Sr. Blvd., Quezon City
721-78-71/721-78-87/721-7877/ 722-06-27 ODC Form 1A
ACTUAL DELIVERY FORM
ACTUAL DELIVERY in Calalang General Hospital, Valenzuela City
Hospital/Home/Lying-In Clinic,Municipality/City/Province
Prepared by:
Printed Name and Signature of Student: Dulay, Bea Kristine S.
Patient's INITIAL (Only)
D.R. Nurse On Duty
Date Performed Case Number SUPERVISED BY
PROCEDURE (Name and Signature)
and (not applicable for Clinical Instructor
PERFORMED (If Midwife on Duty,
Time Started Birthing /Lying- In Name and Signature
Signature not Require)
Clinics/Homes)
June 22, 2009 HR
Normal Spontaneous Delivery
8:45 pm 091075
Ms. Joy Molina, RN Mrs. Vicky M. Parlan, RN,MAN
(Print Name and Signature) (Print Name and Signature)
Noted by: MR. ROMEO G. SAÑO, R.N., M.A.N Approved by: MS. NORIELEE S. MAGSINGIT, R.N., M.A.N
Clinical Coordinator, PRC I.D No 243835 Valid Until December 7, 2013 Dean, PRC I.D. No 162291 Valid Until April 6, 2011
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: R.N., M.A.N Specify Highest Nursing Degree Earned: R.N., M.A.N
(STRICTLY NO DESIGNATES)
