NAGA COLLEGE FOUNDATION, INC.

M.T. VILLANUEVA AVENUE, NAGA CITY PHILIPPINES 4400 ODC Form 1A

Tel.No.: (054) 811-7525 Fax: (054) 811-2417 Email: [email protected] Website: www.ncf.edu.ph ACTUAL DELIVERY FORM
ACTUAL DELIVERY in _BICOL MEDICAL CENTER, NAGA CITY
(Hospital/Home/Lying-In Clinic, Municipality/City/Province)

Prepared by: ____________________________

(Printed Name and Signature of Student)

Patient’s INITIAL
Only D.R. Nurse on Duty
Date Performed SUPERVISED BY
Case Number PROCEDURE (Name and Signature)
and Clinical Instructor
(not applicable for PERFORMED (If Midwife on Duty, Signature Not
Time Started Name and Signature
Birthing/Lying-In Required)
Clinics/ Homes)

Noted by: TERESITA Q. DECAL, MAN, RN Approved by: STANLEY O. DY, Ph.D MAN,RN, RM
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
PRC I.D. No: 0091636 Valid Until: OCT. 25, 2023 PRC I.D. No: 0385217 Valid Until:December 12, 2024
Date Signed: Time: Date Signed: Time:
Highest Nursing Degree: MASTER OF Arts in Nursing Highest Nursing Degree: RN, RM,MAN,PhD.
 NAGA COLLEGE FOUNDATION ODC Form 1B
M.T. VILLANUEVA AVENUE, NAGA CITY PHILIPPINES 4400 ASSISTED DELIVERY FORM
Tel.No.: (054) 811-7525 Fax: (054) 811-2417 Email: [email protected] Website: www.ncf.edu.ph
ASSISTED DELIVERY in _ BICOL MEDICAL CENTER, NAGA CITY __ ____
(Hospital/Home/Lying-In Clinic, Municipality/City/Province)

Prepared by: _______________________

(Printed Name and Signature of Student)

Patient’s INITIAL
Only D.R. Nurse on Duty
Date Performed SUPERVISED BY
Case Number PROCEDURE (Name and Signature)
and Clinical Instructor
(not applicable for PERFORMED (If Midwife on Duty, Signature Not
Time Started Name and Signature
Birthing/Lying-In Required)
Clinics/ Homes)

Noted by: TERESITA Q. DECAL, MAN, RN Approved by: STANLEY O. DY, Ph.D MAN,RN, RM
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
PRC I.D. No: 0091636 Valid Until: OCT. 25, 2023 PRC I.D. No: 0385217 Valid Until:December 12, 2024
Date Signed: Time: Date Signed: Time:
Highest Nursing Degree: MASTER OF Arts in Nursing Highest Nursing Degree: RN, RM,MAN,PhD
 NAGA COLLEGE FOUNDATION ODC Form 1C
M.T. VILLANUEVA AVENUE, NAGA CITY PHILIPPINES 4400 CORD CARE FORM
Tel.No.: (054) 811-7525 Fax: (054) 811-2417 Email: [email protected] Website: www.ncf.edu.ph
IMMEDIATE NEWBORN CORD CARE in _ BICOL MEDICAL CENTER, NAGA CITY
(Hospital/Home/Lying-In Clinic, Municipality/City/Province)

Prepared by: ________________

(Printed Name and Signature of Student)

Patient’s INITIAL Only

Date Performed Immediate Newborn Cord Care SUPERVISED BY
Case Number D.R. Nurse on Duty
and PERFORMED Clinical Instructor
(not applicable for (Name and Signature)
(Indicate where performed e.g: D.R, Nursery, NICU,
Time Started Birthing/Lying-In Clinics/ (If Midwife on Duty, Signature Not Required) Name and Signature
or Home)
Homes)

Noted by: TERESITA Q. DECAL, MAN, RN Approved by: STANLEY O. DY, Ph.D MAN,RN, RM
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
PRC I.D. No: 0091636 Valid Until: OCT. 25, 2023 PRC I.D. No: 0385217 Valid Until:December 12, 2024
Date Signed: Time: Date Signed: Time:
Highest Nursing Degree: Master of Arts in Nursing Highest Nursing Degree: RN, RM,MAN,PhD.
 NAGA COLLEGE FOUNDATION ODC FORM2B
M.T. VILLANUEVA AVENUE, NAGA CITY PHILIPPINES 4400 OR CIRCULATING FORM
Tel.No.: (054) 811-7525 Fax: (054) 811-2417 Email: [email protected] Website: www.ncf.edu.ph
OR CIRCULATING in __ BICOL MEDICAL CENTER, NAGA CITY _
(Hospital, Municipality/City/Province)

Prepared by: ______________________ _________________

(Printed Name and Signature of Student)

Date Performed Patient’s INITIAL Only O.R. Nurse on Duty SUPERVISED BY

SURGICAL PROCEDURE
and (Name and Signature) Clinical Instructor
Case Number PERFORMED
Time Started Name and Signature

Noted by: TERESITA Q. DECAL, MAN, RN Approved by: STANLEY O. DY, Ph.D MAN,RN, RM
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
PRC I.D. No: 0091636 Valid Until: OCT. 25, 2023 PRC I.D. No: 0385217 Valid Until:December 12, 2024
Date Signed: Time: Date Signed: Time:
Highest Nursing Degree: Master of Arts in Nursing Highest Nursing Degree: RN, RM,MAN,PhD.
 NAGA COLLEGE FOUNDATION
M.T. VILLANUEVA AVENUE, NAGA CITY PHILIPPINES 4400
Tel.No.: (054) 811-7525 Fax: (054) 811-2417 Email: [email protected] Website: www.ncf.edu.ph ODC Form 2A
SCRUB FORM
OR SCRUB in ____ BICOL MEDICAL CENTER, NAGA CITY _
(Hospital, Municipality/City/Province)

Prepared by: _____ __________________________

(Printed Name and Signature of Student)
Date Performed Patient’s INITIAL O.R. Nurse on Duty SUPERVISED BY
SURGICAL PROCEDURE
and Only (Name and Signature) Clinical Instructor
PERFORMED
Time Started Case Number Name and Signature

Noted by: TERESITA Q. DECAL, MAN, RN Approved by: STANLEY O. DY, Ph.D MAN,RN, RM
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
PRC I.D. No: 0091636 Valid Until: OCT. 25, 2023 PRC I.D. No: 0385217 Valid Until:December 12, 2024
Date Signed: Time: Date Signed: Time:
Highest Nursing Degree: Master of Arts in Nursing Highest Nursing Degree: RN, RM,MAN,PhD