University of the Immaculate Conception Father Selga Street, Davao City Tel Nos: (63-082) 221-8090; 221-8181; 221-8144

Fax No. (63-082) 226-2676, www.uic.edu.ph

ACTUAL DELIVERY FORM

DR Form

ACTUAL DELIVERY in Prepared by: Printed Name and Signature of Student Date Performed and Time Started

Well Family Midwife Clinic Mintrade Agdao, Davao City BIA ERIKA G. VIOLA PROCEDURE PERFORMED Normal Spontaneous Vaginal Delivery D.R. Nurse on Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) Mrs. Genevieve Berato, RM SUPERVISED BY Clinical Instructor Name and Signature Mrs. Emielyn Relopez, RN Ms. Zarlyn C. Miraflores, RN MN

Patients INITIAL Only Case Number

(not applicable for Birthing/Lying-In Clinics/Homes)

July 16, 2011 10:30 am

L.G.R Case number 00-50-01

Noted by:

Emma D. Umusig, RN, MN 0116600 Valid Until: Time: Master in Nursing May 5, 2014

Noted by:

S. Maria Remegia M. Cirujales, RVM 0104102 Valid Until: Time: MAN, PhD Dev October

Clinical Coordinator, PRC I.D. No. 1, 2013 Date document is signed: Highest Nursing Degree Earned: Studies

Associate Dean, PRC I.D. No. Date document is signed:

Specify Highest Nursing Degree Earned:

(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist]

University of the Immaculate Conception Father Selga Street, Davao City Tel Nos: (63-082) 221-8090; 221-8181; 221-8144 Fax No. (63-082) 226-2676, www.uic.edu.ph

IMMEDIATE CARE OF THE NEWBORN FORM

ICNB Form

IMMEDIATE NEWBORN CORD CARE in Prepared by: Printed Name and Signature of Student Date Performed and Time Started

Medical Mission Group Hospital and Health Services Cooperative of Tagum Tagum City, Davao Del Norte BIA ERIKA G. VIOLA Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home

Patients INITIAL Only Case Number

(not applicable for Birthing Homes /Lying-In Clinics/Homes)

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

SUPERVISED BY Clinical Instructor Name and Signature

August 26, 2010

Baby C Case number 12-63-11

Cord Care Nursery

Ms. Mishael, Panibon RN

Mr. Francis Paolo Oquendo, RN Ms. Zarlyn C. Miraflores, RN MN

Noted by:

Emma D. Umusig, RN, MN 0116600 Valid Until: Time: Master in Nursing May 5, 2014

Noted by:

S. Maria Remegia M. Cirujales, RVM 0104102 Valid Until: Time: MAN, PhD Dev October

Clinical Coordinator, PRC I.D. No. 1, 2013 Date document is signed: Highest Nursing Degree Earned: Studies

Associate Dean, PRC I.D. No. Date document is signed:

Specify Highest Nursing Degree Earned:

(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist]

University of the Immaculate Conception Father Selga Street, Davao City Tel Nos: (63-082) 221-8090; 221-8181; 221-8144 Fax No. (63-082) 226-2676, www.uic.edu.ph

O.R. SCRUB FORM Major

OR Form 1A

SURGICAL SCRUB in

St. John Hospital Toril, Davao City

Prepared by: Printed Name and Signature of Student Date Performed and Time Started

BIA ERIKA G. VIOLA SURGICAL PROCEDURE PERFORMED ECCE with IOL OD O.R. Nurse on Duty (Name AND Signature) Mrs. Gemma S. Abejaron, RN SUPERVISED BY Clinical Instructor Name and Signature Ms. Jenny B. Ramos, RN Ms. Zarlyn C. Miraflores, RN MN

Patients INITIALS (only) Case Number R.L.E Case Number 01-95-37

September 15, 2011 03:40 pm

Noted by:

Emma D. Umusig, RN, MN 0116600 Valid Until: Time: Master in Nursing May 5, 2014

Noted by:

S. Maria Remegia M. Cirujales, RVM 0104102 Valid Until: Time: MAN, PhD Dev October

Clinical Coordinator, PRC I.D. No. 1, 2013 Date document is signed: Highest Nursing Degree Earned: Studies

Associate Dean, PRC I.D. No. Date document is signed:

Specify Highest Nursing Degree Earned:

(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist]

University of the Immaculate Conception Father Selga Street, Davao City Tel Nos: (63-082) 221-8090; 221-8181; 221-8144 Fax No. (63-082) 226-2676, www.uic.edu.ph

O.R. CIRCULATING FORM Major

OR Form 1B

CIRCULATING in Prepared by: Printed Name and Signature of Student Date Performed and Time Started

Midsayap Doctors Community Hospital Midsayap, North Cotabato BIA ERIKA G. VIOLA SURGICAL PROCEDURE PERFORMED Appendectomy O.R. Nurse on Duty (Name and Signature) Mr. Allan Michael Oliveros, RN SUPERVISED BY Clinical Instructor Name and Signature Ms. Jenny B. Ramos, RN Ms. Zarlyn B. Miraflores, RN MN

Patients INITIALS Only Case Number A.S Case Number 1239

December 23, 2011

Noted by:

Emma D. Umusig, RN, MN 0116600 Valid Until: Time: Master in Nursing May 5, 2014

Noted by:

S. Maria Remegia M. Cirujales, RVM 0104102 Valid Until: Time: MAN, PhD Dev October

Clinical Coordinator, PRC I.D. No. 1, 2013 Date document is signed: Highest Nursing Degree Earned: Studies

Associate Dean, PRC I.D. No. Date document is signed:

Specify Highest Nursing Degree Earned:

(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist]