ODC Form 1A HOLY NAME UNIVERSITY ACTUAL DELIVERY FORM Freinademetz Building, Janssen Heights, Dampas District, Tagbilaran

City Telephone Nos. (038) 501-7732, 412 3432, 412 3764, 411 3630, 501 9817 Fax No. (038) 412 3387 / Web- Site: http://www.hnu.edu.ph Accreditation Level: PAASCU - Level III (Education, Arts & Sciences, Commerce and Accountancy), May 2009 until May 2014 Level I (Engineering), August 2007 until May 2010 ACTUAL DELIVERY in _____________________________________________________________________ Hospital / Home / Lying-In Clinic/ Municipality / City/ Province Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started Patients INITIAL Only Case Number (not applicable for Birthing / Lying-In Clinics / Home) PROCEDURE PERFORMED D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUVIH JOY P. GARROTE, RN, MN (Print Name and Signature) Clinical Coordinator, PRC I.D. No. 0143695 Valid Until 12 02 - 2012 Date document is signed: _________________ Time _________________ Please signify Highest Nursing Degree Earned: Master in Nursing

Approved by: ELIZABETH A. FLORESCA, RN, MAN (Print Name and Signature) Dean, PRC I.D. No. 0065648 Valid Until 03 02 2011 Date document is signed: ______________________ Time: ________________ Specify Highest Nursing Degree Earned: Master of Arts in Nursing

ODC Form 2A HOLY NAME UNIVERSITY O.R. SCRUB FORM Freinademetz Building, Janssen Heights, Dampas District, Tagbilaran City Major Telephone Nos. (038) 501-7732, 412 3432, 412 3764, 411 3630, 501 9817 Fax No. (038) 412 3387 / Web- Site: http://www.hnu.edu.ph Accreditation Level: PAASCU - Level III (Education, Arts & Sciences, Commerce and Accountancy), May 2009 until May 2014 Level I (Engineering), August 2007 until May 2010 SURGICAL SCRUB in _____________________________________________________________________ Hospital / Municipality / City/ Province Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started Patients INITIAL Only Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUVIH JOY P. GARROTE, RN, MN (Print Name and Signature) Clinical Coordinator, PRC I.D. No. 0143695 Valid Until 12 02 - 2012 Date document is signed: _________________ Time ________________ Please signify Highest Nursing Degree Earned: Master in Nursing

Approved by: ELIZABETH A. FLORESCA, RN, MAN (Print Name and Signature) Dean, PRC I.D. No. 0065648 Valid Until 03 02 2011 Date document is signed: ______________________ Time: ________________ Specify Highest Nursing Degree Earned: Master of Arts in Nursing

ODC Form 1B HOLY NAME UNIVERSITY ASSISTED DELIVERY Freinademetz Building, Janssen Heights, Dampas District, Tagbilaran City FORM Telephone Nos. (038) 501-7732, 412 3432, 412 3764, 411 3630, 501 9817 Fax No. (038) 412 3387 / Web- Site: http://www.hnu.edu.ph Accreditation Level: PAASCU - Level III (Education, Arts & Sciences, Commerce and Accountancy), May 2009 until May 2014 Level I (Engineering), August 2007 until May 2010 ACTUAL DELIVERY in _____________________________________________________________________ Hospital / Home / Lying-In Clinic/ Municipality / City/ Province Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started Patients INITIAL Only Case Number (not applicable for Birthing / Lying-In Clinics / Home) PROCEDURE PERFORMED ASSISTED DELIVERY D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUVIH JOY P. GARROTE, RN, MN (Print Name and Signature) Clinical Coordinator, PRC I.D. No. 0143695 Valid Until 12 02 - 2012 Date document is signed: _________________ Time _________________ Please signify Highest Nursing Degree Earned: Master in Nursing

Approved by: ELIZABETH A. FLORESCA, RN, MAN (Print Name and Signature) Dean, PRC I.D. No. 0065648 Valid Until 03 02 2011 Date document is signed: ______________________ Time: ________________ Specify Highest Nursing Degree Earned: Master of Arts in Nursing

ODC Form 2B HOLY NAME UNIVERSITY O.R. MINOR FORM Freinademetz Building, Janssen Heights, Dampas District, Tagbilaran City Telephone Nos. (038) 501-7732, 412 3432, 412 3764, 411 3630, 501 9817 Fax No. (038) 412 3387 / Web- Site: http://www.hnu.edu.ph Accreditation Level: PAASCU - Level III (Education, Arts & Sciences, Commerce and Accountancy), May 2009 until May 2014 Level I (Engineering), August 2007 until May 2010 SURGICAL SCRUB in _____________________________________________________________________ Hospital/ Municipality / City/ Province Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started Patients INITIAL Only Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name and Signature) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUVIH JOY P. GARROTE, RN, MN (Print Name and Signature) Clinical Coordinator, PRC I.D. No. 0143695 Valid Until 12 02 - 2012 Date document is signed: _________________ Time _________________ Please signify Highest Nursing Degree Earned: Master in Nursing

Approved by: ELIZABETH A. FLORESCA, RN, MAN (Print Name and Signature) Dean, PRC I.D. No. 0065648 Valid Until 03 02 2011 Date document is signed: ______________________ Time: ________________ Specify Highest Nursing Degree Earned: Master of Arts in Nursing

ODC Form 1C HOLY NAME UNIVERSITY CORD CARE FORM Freinademetz Building, Janssen Heights, Dampas District, Tagbilaran City Telephone Nos. (038) 501-7732, 412 3432, 412 3764, 411 3630, 501 9817 Fax No. (038) 412 3387 / Web- Site: http://www.hnu.edu.ph Accreditation Level: PAASCU - Level III (Education, Arts & Sciences, Commerce and Accountancy), May 2009 until May 2014 Level I (Engineering), August 2007 until May 2010 IMMEDIATE NEWBORN CORD CARE in _____________________________________________________________________ Hospital / Home / Lying-In Clinic/ Municipality / City/ Province Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started Patients INITIAL Only Case Number (not applicable for Birthing / Lying-In Clinics / Home) Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUVIH JOY P. GARROTE, RN, MN (Print Name and Signature) Clinical Coordinator, PRC I.D. No. 0143695 Valid Until 12 02 - 2012 Date document is signed: _________________ Time _________________ Please signify Highest Nursing Degree Earned: Master in Nursing

Approved by: ELIZABETH A. FLORESCA, RN, MAN (Print Name and Signature) Dean, PRC I.D. No. 0065648 Valid Until 03 02 2011 Date document is signed: ______________________ Time: ________________ Specify Highest Nursing Degree Earned: Master of Arts in Nursing