ODC FORM 1A

ACTUAL DELIVERY
FORM
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level II (Jan 1, 2015 Dec. 31, 2018)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
ACTUAL DELIVERY in Gregorio T. Lluch Memorial Hospital
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ECEARCHAN R. BLAZA

Date Performed
and
Time Started

Patients INITIALS(only)

10/17/12
10:10 PM
10/24/12
6:48 PM

Case Number
(not applicable for Birthing/Lyingin Clinics/Homes)
R.V.
042194
N.M.
155358

07/19/13
8:00 PM

G.H.
179190

Noted by: JUDE D. POSITOS, RN, MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0388047
Valid Until: _______________
Date document is signed:
Time: ___________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

PROCEDURE
PERFORMED
Normal Spontaneous Vaginal
Delivery

D.R Nurse On Duty

(Name and Signature)
(If midwife on duty,
Signature Not Required)

Normal Spontaneous Vaginal

Delivery

Mila T.Libot, RN
PRC No. 0130086
Mila T. Libot, RN
PRC No. 0130086

Normal Spontaneous Vaginal

Delivery

Mila T. Libot, RN
PRC No. 0130086

SUPERVISED BY
Clinical Instructor
Name and Signature

Lynuel Santillana, RN, MAN

PRC No. 0382115
Geraldine Sabate-Ridad, RN, MAN
PRC No. 0660326
Elvie A. Paler, RN, MAN
PRC No. 0193311

Approved by: CLOWE D. JONDONERO, RN, MAN

(Print Name and Signature)
Dean, PRC I.D No. 0369698
Valid Until: ______________
Date, document is signed: ___________________Time: __________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

ODC FORM 1B
ASSISTED
DELIVERY FORM
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level II (Jan 1, 2015 Dec. 31, 2018)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
ACTUAL DELIVERY in Gregorio T. Lluch Memorial Hospital
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: ECEARCHAN R. BLAZA

Patients INITIALS(only)
Date Performed
and
Time Started

Case Number
(not applicable for Birthing/Lying-in
Clinics/Homes)

10/28/14
10:05 AM
12/08/14
8:54 AM

D.G.
217732
M.S.
221264

03/03/15
3:07 PM

M.B.
229248

Noted by: JUDE D. POSITOS, RN, MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0388047
Valid Until: _______________
Date document is signed:
Time: ___________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

PROCEDURE
PERFORMED
ASSISTED DELIVERY
Normal Spontaneous Vaginal
Delivery
Normal Spontaneous Vaginal
Delivery
Normal Spontaneous Vaginal
Delivery

D.R Nurse On Duty

(Name and Signature)
(If midwife on duty,
Signature Not Required)
Mila T. Libot, RN
PRC No. 0130086
Mila T. Libot, RN
PRC No. 0130086
Mila T. Libot, RN
PRC No. 0130086

SUPERVISED BY
Clinical Instructor
Name and Signature

Geraldine Sabate-Ridad, RN, MAN

PRC No. 0660326
Elvie A. Paler, RN, MAN
PRC No. 0193311
Arjane C. Pabalan, RN
PRC No. 0656316

Approved by: CLOWE D. JONDONERO, RN, MAN

(Print Name and Signature)
Dean, PRC I.D No. 0369698
Valid Until: ____________
Date, document is signed: ___________________Time: ________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

ODC FORM 1C
CORD CARE
FORM
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level II (Jan 1, 2015 Dec. 31, 2018)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
IMMEDIATE NEWBORN CORD CARE in Gregorio T. Lluch Memorial Hospital
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: ECEARCHAN R. BLAZA

Patients INITIALS(only)
Date Performed
and
Time Started

10/13/14
10:58 AM
03/03/15
8:53 PM
03/10/15
9:40 AM

Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)
216457
228568
229710

Noted by: JUDE D. POSITOS, RN, MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0388047
Valid Until: _______________
Date document is signed:
Time: ___________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Immediate Newborn Cord Care

PERFORMED
Indicate where performed e.g.
D.R., Nursery, NICU, or Home

Cord Care
Cord Care
Cord Care

Nurse On Duty
(Name and Signature)
(If midwife on duty,
Signature Not Required)
Mila T. Libot, RN
PRC No. 0130086
Mila T. Libot, RN
PRC No. 0130086
Mila T. Libot, RN
PRC No. 0130086

SUPERVISED BY
Clinical Instructor
Name and Signature

Geraldine S. Ridad, RN, MAN

PRC No. 0660326
Arjane C. Pabalan, RN
PRC No. 0656316
Geraldine S. Ridad RN, MAN
PRC No. 0660326

Approved by: CLOWE D. JONDONERO, RN, MAN

(Print Name and Signature)
Dean, PRC I.D No. 0369698
Valid Until: ______________
Date, document is signed: ___________________Time: __________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

ODC FORM 2A
O.R. SCRUB FOR
MAJOR
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level II (Jan 1, 2015 Dec. 31, 2018)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

SURGICAL SCRUB in Gregorio T. Lluch Memorial Hospital

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: ECEARCHAN R. BLAZA

Date Performed
and
Time Started

Patients INITIALS(only)

Case Number

SURGICAL PROCEDURE
PERFORMED

O.R Nurse On Duty

(Name and Signature)

07/18/12
7:40 AM

D.B.
146537

Cesarean Section

Belen Joy C.Patindol RN

PRC No: 306764

10/29/14
12:23 PM

R.T
214460

Tension Free Herniorraphy,

Bilateral

Belen Joy C. Patindol RN

PRC No: 306764

2/16/15
1:35 PM

M.G.
227745

Appendectomy

Belen Joy C. Patindol RN

PRC No: 306764

Noted by: JUDE D. POSITOS, RN, MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0388047
Valid Until: _______________
Date document is signed:
Time: ___________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

SUPERVISED BY
Clinical Instructor
Name and Signature
Elvie A. Paler, RN, MAN
PRC No. 0193311
Abdullah Junior S. Mangarun, RN,
MAN
PRC No. 0344352
Elvie A. Paler, RN, MAN
PRC No. 0193311

Approved by: CLOWE D. JONDONERO, RN, MAN

(Print Name and Signature)
Dean, PRC I.D No. 0369698
Valid Until: ______________
Date, document is signed: ___________________Time: __________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

ODC FORM 2B
O.R. CIRCULATING
FORM
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level II (Jan 1, 2015 Dec. 31, 2018)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

SURGICAL SCRUB in Gregorio T. Lluch Memorial Hospital

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: ECEARCHAN R. BLAZA

Date Performed
and
Time Started

Patients INITIALS(only)
SURGICAL PROCEDURE
PERFORMED

Case Number

O.R Nurse On Duty

(Name and Signature)

10/29/14
10:02 AM

K.L.
217266

Close Treatment + Application of Hip

Spica 11/2 left Femur

Belen Joy C. Patindol RN

PRC No: 306764

10/29/14
3:45PM

I.P.
217829

Tension Free Herniorraphy Left

Belen Joy C. Patindol RN

PRC No: 306764

03/17/15
9:06 PM

M.H.
228505

Total Abdominal Hysterectomy with

Bilateral Salpingo-Oopherectomy

Belen Joy C. Patindol RN

PRC No: 306764

Noted by: JUDE D. POSITOS, RN, MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0388047
Valid Until: _______________
Date document is signed:
Time: ___________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

SUPERVISED BY
Clinical Instructor
Name and Signature
Abdullah Junior S. Mangarun, RN,
MAN
PRC No. 0344352
Abdullah Junior S. Mangarun, RN,
MAN
PRC No. 0344352
John Paul Ben T. Silang, RN, MAN
PRC No. 453695

Approved by: CLOWE D. JONDONERO, RN, MAN

(Print Name and Signature)
Dean, PRC I.D No. 0369698
Valid Until: ______________
Date, document is signed: ___________________Time: __________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING