MARTINEZ MEMORIAL COLLEGES

198 A. Mabini Street, Maypajo, Caloocan City Tel. No. 288-4279 / 287-5003

ODC Form 1 B ASSISTED DELIVERY FORM

ACTUAL DELIVERY in__________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student : _________________________________________

DATE

TIME

Patient's INITIAL Only

____________ Case Number

PROCEDURE PERFORMED ASSISTED DELIVERY

D.R. NURSE ON DUTY

( Name and Signature )

SUPERVISED BY
Clinical Instructor Name and Signature

Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________

Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________

MARTINEZ MEMORIAL COLLEGES

198 A. Mabini Street, Maypajo, Caloocan City Tel. No. 288-4279 / 287-5003

ODC Form 2 B O.R. CIRCULATING FORM

SURGICAL SCRUB in__________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________

DATE

TIME

PATIENTS INITIALS ONLY

____________ Case Number

SURGICAL PROCEDURE PERFORMED

O.R. NURSE ON DUTY

( Name and Signature )

SUPERVISED BY
Clinical Instructor Name and Signature

Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________

Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________

MARTINEZ MEMORIAL COLLEGES

198 A. Mabini Street, Maypajo, Caloocan City Tel. No. 288-4279 / 287-5003

ODC Form 2 B O.R. SCRUB FORM Major

SURGICAL SCRUB in__________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________

DATE

TIME

PATIENTS INITIALS ONLY

____________ Case Number

SURGICAL PROCEDURE PERFORMED

O.R. NURSE ON DUTY

( Name and Signature )

SUPERVISED BY
Clinical Instructor Name and Signature

Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________

Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________

MARTINEZ MEMORIAL COLLEGES

198 A. Mabini Street, Maypajo, Caloocan City Tel. No. 288-4279 / 287-5003

ODC Form 1 A ACTUAL DELIVERY FORM

ACTUAL DELIVERY in__________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________

DATE

TIME

PATIENTS INITIAL ONLY

____________ Case Number

PROCEDURE PERFORMED

D.R. NURSE ON DUTY

( Name and Signature )

SUPERVISED BY
Clinical Instructor Name and Signature

Noted by:

Approved by:

( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________

( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________

MARTINEZ MEMORIAL COLLEGES

198 A. Mabini Street, Maypajo, Caloocan City Tel. 288-4279 / 287-5003

CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in_____________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name and Signature of Student :_________________________________________

DATE

TIME

PATIENTS INITIAL ONLY

____________ Case Number

Immediate Newborn Cord Care Performed

Indicate where Performed

NURSE ON DUTY
( Name and Signature )

SUPERVISED BY
Clinical Instructor Name and Signature

Noted by: ( Print Name and Signature ) Clinical Coordinator, PRC ID No._____________ Valid Until _________ Date Document is Signed ____________________ Time ______________ Please Specify Highest Nursing Degree Earned _____________________

Approved by: ( Print Name and Signature ) Dean, PRC ID No.___________________ Valid Until _________ Date Document is Signed _____________ Time _____________ Please Specify Highest Nursing Degree Earned _______________