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St. Anthony College of Roxas City, Inc.

San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

ODC Form 1A
ACTUAL DELIVERY FORM

Government Recognition No. 012; Series of 1982 July 6, 1981 ACTUAL DELIVERY in Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time of Delivery Patients INITIAL only Case Number D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature

(not applicable for Birthing/ Lying-in Clinics/Homes)

PROCEDURE PERFORMED

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D 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: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

St. Anthony College of Roxas City, Inc.


San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

ODC Form 1B
ASSISTED Delivery FORM

Government Recognition No. 012; Series of 1982 July 6, 1981 ACTUAL DELIVERY in Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Date Performed and Time of Delivery Patients INITIAL only Case Number

PROCEDURE PERFORMED
ASSISTED DELIVERY

(not applicable for Birthing/ Lying-in Clinics/Homes)

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D 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: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

St. Anthony College of Roxas City, Inc.


San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

ODC Form 1C
CORD CARE FORM

Government Recognition No. 012; Series of 1982 July 6, 1981 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 of Delivery Patients INITIAL only Case Number Immediate Newborn Cord Care PERFORMED D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required) SUPERVISED BY Clinical Instructor Name and Signature

(not applicable for Birthing/ Lying-in Clinics/Homes)

Indicate where performed e.g. D.R., Nursery, NICU, or Home

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D 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: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

St. Anthony College of Roxas City, Inc.


San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

ODC Form 2A
O.R. SCRUB FORM Major

Government Recognition No. 012; Series of 1982 July 6, 1981 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 O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature

SURGICAL PROCEDURE PERFORMED

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D 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: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

St. Anthony College of Roxas City, Inc.


San Roque Extension, Roxas City 5800 Capiz, Philippines Telephone No.: (036) 621-0431 local 163 Fax No.: (036) 621-4185 Website: http://sach.dcphilippines.org

ODC Form 2B
O.R. CIRCULATING FORM

Government Recognition No. 012; Series of 1982 July 6, 1981 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 O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature

SURGICAL PROCEDURE PERFORMED

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D 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: Specify Highest Nursing Degree Earned: (STRICTLY NO DESIGNATES)

Valid Until: Time:

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