ODC Form 1A ACTUAL DELIVERY FORM ACTUAL DELIVERY in RAFAEL LAZATIN MEMORIAL MEDICAL CENTER Angeles City, Pampanga

Hospital / Home / lying-in Clinic, Municipality / City / Province

Prepared by: Ma. Luisa G. Roque Printed Name and Signature of Student Date Performed and Time Started Patients INITIAL Only Case Number (Not applicable for Birthing / Lying-in Clinics / Homes) PROCEDURE PERFORMED D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) SUPERVISED BY Clinical Instructor Name and Signature

Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN

Noted by: Mr. Erwin R. Pernia, R.N., MAN Clinical Coordinator, PRC I.D. No._0275864 Valid Until: February 20, 2015 Date document is signed: April 16, 2012 Time: 10:00am Please specify Highest Nursing Degree Earned: MAN

Approved by: Mr. Constantine G. Sazon, R.N., MN Dean, College of Nursing, PRC I.D. No. 0161726 Valid Until: January 03, 2015 Date document is signed: April 16, 2012 Time: 10:00am Specify Highest Nursing Degree Earned: MN

ODC Form 2A O.R. SCRUB FORM Major SURGICAL SCRUB in JOSE B. LINGAD GENERAL HOSPITAL, City of San Fernando, Pampanga Hospital / Home / City / Province Prepared by: Ma. Luisa G. Roque Printed Name and Signature of Student Patients INITIAL Only Date Performed and Time Started Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN Noted by: Mr. Erwin R. Pernia, R.N., MAN Clinical Coordinator, PRC I.D. No._0275864 Valid Until: February 20, 2015 Date document is signed: April 16, 2012 Time: 10:00am Please specify Highest Nursing Degree Earned: MAN Approved by: Mr. Constantine G. Sazon, R.N., MN Dean, College of Nursing, PRC I.D. No. 0161726 Valid Until: January 03, 2015 Date document is signed: April 16, 2012 Time: 10:00am Specify Highest Nursing Degree Earned: MN

ODC Form 2b OR CIRCULATING FORM OR CIRCULATING in: JOSE B. LINGAD GENERAL HOSPITAL, City of San Fernando, Pampanga Hospital, Municipality / City / Province

Prepared by: Ma. Luisa G. Roque Printed Name and Signature of Student: Date Performed and Time Started Patients INITIAL Only Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name and Siganature) SUPERVISED BY Clinical Instructor Name and Signature Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN

Noted by: Mr. Erwin R. Pernia, R.N., MAN Clinical Coordinator, PRC I.D. No. _0275864 Valid Until: February 20, 2015 Date document is signed: April 16, 2012 Time: 10:00am Please specify Highest Nursing Degree Earned: MAN

Approved by: Mr. Constantine G. Sazon, R.N., MN Dean, College of Nursing, PRC I.D. No. 0161726 Valid Until: January 03, 2015 Date document is signed: April 16, 2012 Time: 10:00am Specify Highest Nursing Degree Earned: MN

ODC Form 1A CORD CARE FORM CORD CARE in RAFAEL LAZATIN MEMORIAL MEDICAL CENTER Angeles City, Pampanga Hospital / Home / lying-in Clinic, Municipality / City / Province

Prepared by: Ma. Luisa G. Roque Printed Name and Signature of Student Date Performed and Time Started Patients INITIAL Only Case Number (Not applicable for Birthing / Lying-in Clinics / Homes) Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) SUPERVISED BY Clinical Instructor Name and Signature

Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN Mr. Erwin R. Pernia RN, MAN Noted by: Mr. Erwin R. Pernia, R.N., MAN Clinical Coordinator, PRC I.D. No. _0275864 Valid Until: February 20, 2015 Date document is signed: April 16, 2012 Time: 10:00am Please specify Highest Nursing Degree Earned: MAN Approved by: Mr. Constantine G. Sazon, R.N., MN Dean, College of Nursing, PRC I.D. No. 0161726 Valid Until: January 03, 2015 Date document is signed: April 16, 2012 Time: 10:00am Specify Highest Nursing Degree Earned: MN