MANUEL S. ENVERGA UNIVERSITY FOUNDATION CANDELARIA INC.

ODC FORM 1A
Candelaria, Quezon ACTUAL DELIVERY
FORM
ACTUAL DELIVERY in Magsaysay Memorial District Hospital, Lopez, Quezon

Printed Name with Signature of Student: Ezekiel R. Lopez

Prepared by: LOPEZ, EZEKIEL DELOS REYES

Date Performed Patient's Name DR Nurse on Duty Supervised by

and Case Number Procedure Performed (Names Only) Clinical Instructor
Time Started (not applicable for Birthing/ Lying in Clinics/ Homes) Name and Signature

March 1,2010 Maricel P. Panganiban Normal Spontaneous Delivery Glady Erandio Joan Grace C. Piguerra
2:30 PM 80605 0355717
PRC no. 0255717

May 28, 2009 Genalyn A. Valenzuela Normal Spontaneous Delivery Glady Erandio Joan Grace C. Piguerra
11:34 AM 75732 0355717
PRC no. 0255717

Noted By: Rosario Natividad C. Bautista RN, MAN Approved by: Gaspar Hector C. Tapire, RN, MSN
Clinical Coordinator Dean

PRC ID No. 0184950 Valid Until October 20, 2012 PRC ID No. 0214894 Valid Until November 4, 2011
Date Signed Time Date Signed Time
PNA No. 009710 Valid Until October 31, 2010 PNA No. 051961 Valid Until October 31, 2010
ADPCN No. 0847 Valid Until December 31, 2010
Concurred by LOIDA GUIA RN
Chief Nurse

PRC ID No. 082950 Valid Until November 21, 2011

Date Signed Time
PNA No. 6100 Valid Until life member