University of the Cordilleras

Governor Pack Road, Baguio City, Philippines 2600

(+6374) 442-3316, 442-2564, 442-8219, 442-8256
e-mail: webmaster@bcf.edu.ph
website: www.bcf.edu.ph

ODC Form 1A
ACTUAL DELIVERY
FORM

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/Lyingin Clinics/Homes)

PROCEDURE PERFORMED

Noted by: _________________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. :___________ Valid Until: ________
Date document is signed: _________________ Time: _____________
Please specify Highest Nursing Degree Earned:
_________________________

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ________

___________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. _____________ Valid Until: __________________________
Date document is signed: ____________ Time: _________________________
Specify Highest Nursing Degree Earned:
_______________________________
(STRICTLY NO DESIGNATES)