ODC Form 1A

UNIVERSITY OF SAN AGUSTIN

GENERAL LUNA STREET, ILOILO CITY
ACTUAL DELIVERY FORM
Tel. No.: (033)337-48-41 to 44 Local 259, Fax No.: (033)337-44-03, E-mail Address: cn@usa.edu.ph, Web-Site: www.usa.edu.ph

ACTUAL DELIVERY in Calumpang Health Center Lying in, Iloilo City

Hospital/Home/Lying in clinic/Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: ___ ______________________________________________________

Date Performed Patient’s Initial Only D.R. Nurse on Duty SUPERVISED BY

and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not applicable for birthing/lying-in clinics/home) If midwife on duty signature not required Name and Signature

Noted: ViellaTolosa- Balbon, R.N.____________________________________________ Approved : Sofia Cosette P. Monteblanco, R.N._________________________________

(Print Name and Signature) (Print Name and Signature)
Academic Supervisor, PRC I.D. No.0247373 Valid Until August 26, 2021__________ Dean, PRC I.D. No. 0042682_______________ Valid Until February 1, 2022_________
Date document is signed:_________________ Time____________________________ Date document is signed:_________________ Time____________________________
Please Specify Highest Nursing Degree Earned:___MA.Ed,M.A.N.___________________ Please Specify Highest Nursing Degree Earned:___M.A.N._________________________