ODC Form 1A

ACTUAL DELIVERY FORM

WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities of the Philippines / Level II Re-accredited / February 2009
ACTUAL DELIVERY in _____________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: _______________________________

Date Performed Patient’s INITIALS (only) D.R. Nurse On Duty SUPERVISED BY:
and
Case Number
PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
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 in Nursing

ODC Form 1B
ASSISTED DELIVERY
WESTERN MINDANAO STATE UNIVERSITY FORM
 Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities of the Philippines / Level II Re-accredited / February 2009
ASSISTED DELIVERY in ____________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: __________________________

Date Performed Patient’s INITIALS (only) D.R. Nurse On Duty SUPERVISED BY:
PROCEDURE
and (Name and Signature) Clinical Instructor
Case Number PERFORMED
Time Started Name and Signature

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
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 in Nursing
ODC Form 1C
CORD CARE FORM

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
 Accredited by: Accrediting Agency of Chartered Colleges and Universities of the Philippines / Level II Re-accredited / February 2009
IMMEDIATE NEWBORN CORD CARE in __________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ____________________________________

Patient’s INITIALS
Date Performed Immediate Newborn Cord SUPERVISED BY:
(only) D.R. Nurse On Duty
and Care PERFORMED Clinical Instructor
Indicate where performed e.g. D.R., (Name and Signature)
Time Started Case Number Name and Signature
Nursery, NICU, or Home

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Highest Nursing Degree Earned:__________ Master in Nursing Highest Nursing Degree Earned: _______Master in Nursing _______
ODC Form 2B
MINOR
FORM
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities of the Philippines / Level II Re-accredited / February 2009
 SURGICAL SCRUB in _______________________________
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: _________________________________

Date Performed Patient’s INITIALS SUPERVISED BY:

(only) SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Name and Signature
Case Number

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Highest Nursing Degree Earned: ____________Master in Nursing _________ Highest Nursing Degree Earned: Master in Nursing________

ODC Form 2A
O.R. SCRUB FORM
WESTERN MINDANAO STATE UNIVERSITY Major
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities of the Philippines / Level II Re-accredited / February 2009
SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province
Prepared by:
Printed Name with Signature of Student: ______________________________

Date Performed Patient’s INITIALS SUPERVISED BY:

(only) SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
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 in Nursing