UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

Operating Room Form(Major and Minor)

Delivery Room Form(Delivery. Assist, and Cord Care)

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED

O.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

November 26,2009 – 6:47PMF.A.65139-09

Primary Low Segment Transverse Caesarian Section Mrs. Rowena M. Escasinas Ms. Melinda Rabutin

July 26,2010 – 9:30 AMR.C.L.166907

Lobectomy Right, Isthmusectomy Mrs. Rowena M. Escasinas Dr. Betty Lynn C. Garingo

July 27,2010 – 10:50 AMD.G.B.161740

Cystoscopy, CystolithotripsyMs. Florence N. Juntilla Dr. Betty Lynn C. Garingo

July 27,2010 – 1:30 PMF.D.M.C.160179

Herniorrhapy Mesh RepairMrs. Lilibeth L. Punay Dr. Betty Lynn C. Garingo

July 30,2010 – 8:55 AMG.B.D.169131

AppendectomyMrs. Rowena M. Escasinas Dr. Betty Lynn C. Garingo

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)Republic of the Philippines

ODC Form 2AO.R. SCRUB FORM major

ODC Form 2BO.R. CIRCULATING FORM

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in VICENTE GULLAS MEDICAL CENTER/BANILAD/MANDAUE CITY Hospital/ Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED

O.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

November 27,2009 – 4:00 PMD.T.M.01-0334

DebridementMs. Lenie M. Sombilon Mr. Phillip Mark Bueno

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

Republic of the Philippines

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in LAPU-LAPU DISTRICT HOSPITAL/LAPU-LAPU CITY Hospital/ Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED

O.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

January 26,2010 – 7:30 PMR.P.B.2010-266

SuturingMrs. Gina Gollez Menguito Mr. Wilson B. Maxilom

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 2BO.R. CIRCULATING FORM

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED

O.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

October 13,2010J.S.A.10-10017

EpisiorraphyMs. Teresita Y. Sayson Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

Republic of the Philippines

ODC Form 2BO.R. CIRCULATING FORM

ODC Form 2BO.R. CIRCULATING FORM

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED

O.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

August 25,2009 – 9:05 AMS.N.P.65937 - 2009

Excision BiopsyMrs. Preciosa V. Borinaga Mrs. Josephine A. Alo

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

Republic of the PhilippinesProfessional Regulation Commission

ODC Form 1AActual Delivery Form

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in GRENGIA MATERNITY HOUSE/LAPU-LAPU Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty(Name AND Signature)

(If Midwife on duty, Signature not required)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

December 09,2009 – 1:51 PMA.A.1599-2009

Normal Spontaneous Vaginal Delivery Dr. Josephus Grengia Mrs. Loida B. Alondres

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

Republic of the Philippines

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in EVERSLY CHILD SANITARIUM/JAGOBIA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty(Name AND Signature)

(If Midwife on duty, Signature not required)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

January 29,2010 – 10:15 AMS.G.085249

Normal Spontaneous Vaginal Delivery Ms. Jasmin A. Pepito Mrs. Loida B. Alondres

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1AActual Delivery Form

Republic of the Philippines

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty(Name AND Signature)

(If Midwife on duty, Signature not required)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

October 14, 2010 – 1:43 PMS.O.T.10-10090

Normal Spontaneous Vaginal Delivery Mrs. Teresita Y. Sayson Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1AActual Delivery Form

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only PROCEDURE PERFORMED

ASSISTED DELIVERY

D.R. Nurse on Duty(Name AND Signature)

(If Midwife on duty, Signature not required)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

July 10,2009 – 1:20 AMA.D.55622-2009

Normal Spontaneous Vaginal Delivery

Mrs. Nelpha B. Obordo Mrs. Ma. Flor L. Operario

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1BASSISTED Delivery Form

Republic of the Philippines

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in EVERSLY CHILD SANITARIUM/JAGOBIA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only PROCEDURE PERFORMED

ASSISTED DELIVERY

D.R. Nurse on Duty(Name AND Signature)

(If Midwife on duty, Signature not required)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

January 25,2010 – 9:50 AMA.T.024950

Normal Spontaneous Vaginal Delivery Ms. Jasmin A. Pepito Mrs. Loida B. Alondres

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1BASSISTED Delivery Form

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in MANDAUE CITY HOSPITAL/MANDAUE CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only PROCEDURE PERFORMED

ASSISTED DELIVERY

D.R. Nurse on Duty(Name AND Signature)

(If Midwife on duty, Signature not required)

SUPERVISED BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

May 12,2010 – 9:44 PMZ.T.N.13832-A

Normal Spontaneous Vaginal Delivery Mrs. Ma. Georgia Lada Mr. Sergio Valiente

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1BASSISTED Delivery Form

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only 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 BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

May 19,2010 – 12:40 AMJ.D.O.148083

Neonate Intensive Care UnitMrs. Ediza P. Sabang Mrs. Armida B. Gutierrez

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1CCORD CARE FORM

Republic of the Philippines

Professional Regulation CommissionBoard of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in LAPU-LAPU DISTRICT HOSPITAL/LAPU-LAPU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only 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 BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

July 12,2010 – 8:30 PMA.D.M.40682

Delivery RoomMrs. Ma. Lilane D. Berdin Mrs. Edna E. Reroma

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1CCORD CARE FORM

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only 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 BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

October 12,2010 – 11:57 AMC.N.A.1010200

Delivery RoomMrs. Teresita Y. Sayson Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1CCORD CARE FORM

Republic of the PhilippinesProfessional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYASCollege of Nursing

Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622

Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed andTime Started

Patient’s INITIAL only 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 BYClinical Instructor

Name and SignatureCase Number

(not applicable for Birthing Homes/Lying-in clinics/Homes)

October 12,2010 – 4:27 PMJ.M.O.10-10014

Delivery RoomMrs. Mary M. Aberia Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1CCORD CARE FORM