UNIVERSITY OF SAN CARLOS

ODC Form 1A
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
ACTUAL DELIVERY FORM
PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

ACTUAL DELIVERY in CEBU CITY MEDICAL CENTER, N. BACALSO ST., CEBU CITY
Hospital/ Home/ Lying-in Clinic, Municipality/ City/ Province

Prepared by:

Printed Name with Signature of Student: _________________________________

Patient’s INITIALS (only)

Date Performed and D.R. Nurse On Duty SUPERVISED BY
Case Number (Name and Signature) Clinical Instructor
Time Started (not applicable for Birthing/ PROCEDURE PERFORMED
Lying-in Clinics/ Homes) (if Midwife on Duty, Signature not required) (Name and Signature)

ACTUAL DELIVERY

(STRICTLY NO DESIGNATES)
Noted by: Laarne E. Pontillas, R.N., M.S.N., M.A.N. Approved by: Antonia F. Pascual, R.N., M.N., M.S.N.
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0190308 Valid Until June 22, 2011 Clinical Coordinator, PRC I.D. No. 0054229 Valid Until August 5, 2012
Date document is signed ______________ Time ________________ Date document is signed ______________ Time ________________

Please specify Highest Nursing Degree Earned Master of Science in Nursing Please specify Highest Nursing Degree Earned Master in Nursing

Master of Arts in Nursing Master of Science in Nursing