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FILAMER CHRISTIAN UNIVERSITY
ROXAS CITY, PHILIPPINES
Tele-Fax No.6213-075/Email: fcc_registrar@yahoo.com
(Accredited by ACSCU- AAI, Level II)

ACTUAL DELIVERY in ____________________________________________________ Hospital/Home/Lying – in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student _______________________________________

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