Republic of the Philippines

ODC Form 1A
Bicol University Tabaco Campus
Actual Delivery Form
Nursing Department
Tabaco City

ACTUAL DELIVERY in _________________________________________________

Hospital, Municipality/ City/ Province

Prepared by:

Printed Name with Signature of Student: ____________________________________

Date Performed Patient’s INITIALS (only) PROCEDURE PERFORMED D.R. Nurse On Duty SUPERVISED BY
and (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying- Signature NOT
In Clinic/Homes) Required)

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned:
 Republic of the Philippines
ODC Form 1B
Bicol University Tabaco Campus
Assisted Delivery Form
Nursing Department
Tabaco City

ASSISTED DELIVERY in _________________________________________________

Hospital, Municipality/ City/ Province

Prepared by:

Printed Name with Signature of Student: ____________________________________

Date Performed Patient’s INITIALS (only) PROCEDURE PERFORMED D.R. Nurse On Duty SUPERVISED BY
and (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying- Signature NOT
In Clinic/Homes) Required)

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned:
 Republic of the Philippines
ODC Form 1C
Bicol University Tabaco Campus
Cord Care Form
Nursing Department
Tabaco City

IMMEDIATE CARE OF NEWBORN in _________________________________________________

Hospital, Municipality/ City/ Province

Prepared by:

Printed Name with Signature of Student: ____________________________________

Date Performed Patient’s INITIALS (only) Immediate Newborn Cord Care NICU Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying- NICU, or Home Signature NOT
In Clinic/Homes) Required)

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned:
 Republic of the Philippines
ODC Form 2A
Bicol University Tabaco Campus
OR Scrub Form
Nursing Department
Tabaco City

SURGICAL SCRUB in _________________________________________________

Hospital, Municipality/ City/ Province
Prepared by:

Printed Name with Signature of Student: ____________________________________

Date Performed Patient’s INITIALS (only) SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned:
 Republic of the Philippines
ODC Form 2B
Bicol University Tabaco Campus
OR Circulating Form
Nursing Department
Tabaco City

SURGICAL SCRUB in _________________________________________________

Hospital, Municipality/ City/ Province

Prepared by:

Printed Name with Signature of Student: ____________________________________

Date Performed Patient’s INITIALS (only) SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number

Noted by: Approved by:

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