COR JESU COLLEGE, INC.

Sacred Heart Avenue, Digos City, Davao del Sur

Tel. No. 553-9714/ Fax No.: (082) 553-2333/ hsd_cjc@yahoo.com/www.cjc.edu.ph
(IF ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation)

ASSISTED DELIVERIES
Prepared by:

Printed Name and Signature of Student:

Date Performed Patient’s Complete Name and Age PROCEDURE PERFORMED Name and Signature of SUPERVISED BY
and D.R. Nurse-On-Duty
Time Started Case Number ASSISTED DELIVERY Name and Signature of
(not applicable for (If Midwife on Duty, Signature Clinical Instructor
Birthing Homes/ Lying-in Clinic) Not Required)

Case Number:

Case Number:

Case Number:

Case Number:

Case Number:

Noted by: AILEEN A. MONARES, RN, MN Approved by: ANTONINA H. REBATO, RN, MAN
(Printed Name and Signature) (Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0323800 Valid Until: September 07, 2024 Dean, PRC I.D. No.: 0157878 Valid Until: July 6, 2023
Date Document is signed: Time: Date Document is signed: Time:
Please specify Highest Nursing Degree Earned: MASTER IN NURSING Please specify Highest Nursing Degree Earned: MAN, CAR Ed.D