St. Anthony College of Roxas City, Inc.

ODC Form 1B
San Roque Extension, Roxas City 5800 Capiz, Philippines ASSISTED Delivery
Telephone No.: (036) 621-0431 local 163
FORM
Fax No.: (036) 621-4185
Website: http://sach.dcphilippines.org
Government Recognition No. 012; Series of 1982 – July 6, 1981
ACTUAL DELIVERY in ROXAS CITY HEALTH BIRTHING CLINIC
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: REA KATRINA ASIGNACION BERNALES

Patient’s INITIAL only PROCEDURE D.R. Nurse On Duty

Date Performed SUPERVISED BY
and Case Number PERFORMED (Name and Signature)
Clinical Instructor
(not applicable for Birthing/ Lying-in (If Midwife on Duty,
Time of Delivery Name and Signature
Clinics/Homes) ASSISTED DELIVERY Signature not Required)
SEPTEMBER 23, 2015 NORMAL SPONTANEOUS VAGINAL
J.B MARISSA B. BARRIOS, RN HAZEL RODA ESTORQUE, RN, LPT
10:33 AM DELIVERY
JANUARY 21, 2017 NORMAL SPONTANEOUS VAGINAL
J.P MARISSA B. BARRIOS, RN MAUREEN P. TAJOLOSA, RN, RM
9:16 AM DELIVERY

JANUARY 23,2018 NORMAL SPONTANEOUS VAGINAL

J.A.D.J MARISSA B. BARRIOS, RN GELINE A. BORAL, RM, RN
5:57 AM DELIVERY

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until: Dean, PRC I.D No. Valid Until:
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO DESIGNATES)
 St. Anthony College of Roxas City, Inc. ODC Form 1A
San Roque Extension, Roxas City 5800 Capiz, Philippines ACTUAL DELIVERY FORM
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://sach.dcphilippines.org
Government Recognition No. 012; Series of 1982 – July 6, 1981
ACTUAL DELIVERY in ROXAS CITY HEALTH BIRTHING CLINIC
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: CARLA BUENAVISTA COMPARACION

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 Birthing/ Lying-in PERFORMED (If Midwife on Duty,
Time of Delivery Name and Signature
Clinics/Homes) Signature not Required)
FEBRUARY 09, 2016 NORMAL SPONTANEOUS VAGINAL
E.A MARISSA B. BARRIOS, RN HAZEL RODA A. ESTORQUE, RN, LPT
9:55 AM DELIVERY
SEPTEMBER 12, 2017 NORMAL SPONTANEOUS VAGINAL
E.A MARISSA B. BARRIOS, RN MAUREEN P. TAJOLOSA, RN, RM
12:54 PM DELIVERY

JANUARY 25, 2018 NORMAL SPONTANEOUS VAGINAL

M.A MARISSA B. BARRIOS, RN GELINE A. BORAL, RM, RN
3:45 AM DELIVERY

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until: Dean, PRC I.D No. Valid Until:
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned:

(STRICTLY NO DESIGNATES)
 St. Anthony College of Roxas City, Inc. ODC Form 1C
San Roque Extension, Roxas City 5800 Capiz, Philippines CORD CARE FORM
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://sach.dcphilippines.org
Government Recognition No. 012; Series of 1982 – July 6, 1981
IMMEDIATE NEWBORN CORD CARE in ROXAS CITY HEALTH BIRTHING CLINIC
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: REA KATRINA ASIGNCAION BERNALES

Patient’s INITIAL only Immediate Newborn Cord Care D.R. Nurse On Duty
Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(not applicable for Birthing/ Lying-in Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty,
Time of Delivery Name and Signature
Clinics/Homes) NICU, or Home Signature not Required)
OCTOBER 6, 2015
BABY BOY CATALAN DELIVERY ROOM MARISSA B. BARRIOS, RN HAZEL RODA ESTORQUE, RN, LPT
11:48 AM

SEPTEMBER 12,2017
BABY GIRL ALAYON DELIVERY ROOM MARISSA B. BARRIOS, RN MAUREEN P. TAJOLOSA, RN, RM
10:50 AM

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. Valid Until: Dean, PRC I.D No. Valid Until:
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Specify Highest Nursing Degree Earned: