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UNIVERSITYofPANGASINAN

PHINMA EDUCATION NETWORK University Seal


COLLEGE OF NURSING
Arellano St. Dagupan City

Phone No. (075)522-5635-37; Fax No. (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Date School/Program was recognized: May 19, 1976; Number 44; Year: 1976)
(Level I PACUCOA; Year Granted: March 05, 2007)

ACTUAL DELIVERY IN___________REGION 1 MEDICAL CENTER / DAGUPANG CITY PANGASINAN__________________


Hospital/Home/Lying-in Clinic/Municipality/City/Province

Prepared by: D.R Form 1A


Printed Name with Signature of Student: DE LA CRUZ, SHAIRA FERRER _______________________________ Actual Delivery
FORM

Date Performed Patient’s INITIAL only Supervised by:


And PROCEDURE PERFORMED D.R NURSE ON DUTY CLINICAL INSTRUCTOR
Time Started Case Number (Name and Signature)
(Not Applicable for
Birthing/Lying-in Clinics/Homes
C.T.T
February 14, 2019 NORMAL SPONTANEOUS DELIVERY JOCELYN M. CAYABYAB, R.N., M.A.N. AMELITA D. DUMAGUIN, R.N., M.A.N.
64416
1:03 PM

Noted by: LIZA D. FUCANAN__ ___ Approved by: __ MARIA TERESA R. FAJARDO_________
Clinical Coordinator College Dean

PRC I.D No. . 0108608___________________Valid Until: January 01,2020 PRC I.D No. 0160104_____________ Valid Until: September 09, 2019

Date document is signed: ___________________Time:________________ Date document is signed: Time: _______________________


Please Specify Degree Earned: RN, MAN___________________________ Please Specify Degree Earned: RN, MAN, Ed.D (in progress)______________________

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