University of Perpetual Help System DALTA Alabang Zapote Road, Pamplona, Las Pias City COLLEGE OF NURSING (02)

2) 871-0639 / www.perpetual.edu.ph PACUCOA Accredited Level III Status, Valid until 2015

ACTUAL DELIVERY in Hospital/Lying-in Clinic Municipality/City/Province Prepared by: Printed Name and Signature of the Student DATE PERFORMED AND TIME STARTED PATIENTS INITIAL ONLY CASE NUMBER (Not applicable for Birthing Lying-in Clinics/Homes)

PROCDURE PERFORMED

D.R. NURSE ON DUTY (Name and Signature) (If Midwife on Duty, Signature not required)

SUPERVISED BY (Clinical Instructors Name and Signature)

Noted by: Clinical Coordinator PRC ID No.: Valid Until:

Noted by: Dean PRC ID No.: Valid Until:

University of Perpetual Help System DALTA Alabang Zapote Road, Pamplona, Las Pias City COLLEGE OF NURSING (02) 871-0639 / www.perpetual.edu.ph PACUCOA Accredited Level III Status, Valid until 2015

IMMEDIATE NEWBORN CORD CARE in Hospital/Lying-in Clinic Municipality/City/Province Prepared by: Printed Name and Signature of the Student DATE PERFORMED AND TIME STARTED PATIENTS INITIAL ONLY CASE NUMBER (Not applicable for Birthing Lying-in Clinics/Homes)

IMMEDIATE NEWBORD CORD CARE PERFORMED Indicate where performed e.g. DR, Nursery, NICU or Home

NURSE ON DUTY (Name and Signature) (If Midwife on Duty, Signature not required)

SUPERVISED BY (Clinical Instructors Name and Signature)

Noted by: Clinical Coordinator PRC ID No.: Valid Until:

Noted by: Dean PRC ID No.: Valid Until: