St. Anthony College of Roxas City, Inc.

ODC Form 1A
San Roque Extension, Roxas City 5800 Capiz, Philippines ACTUAL DELIVERY FORM
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://www.sachri.edu.ph
Government Recognition No. 012; Series of 1982 – July 6, 1981
ACTUAL DELIVERY in ROXAS CITY HEALTH BIRTHING CLINIC
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: MICHELLE BURGOS ALOVERA

Patient’s INITIAL only D.R. Nurse On Duty

Date Performed SUPERVISED BY
Case Number PROCEDURE (Name and Signature)
and Clinical Instructor
(not applicable for Birthing/ PERFORMED (If Midwife on Duty,
Time of Delivery Name and Signature
Lying-in Clinics/Homes) Signature not Required)

JANUARY 18, 2020 NORMAL SPONTANEOUS

S.A. ANN A. FRANCISCO, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
5:51 AM VAGINAL DELIVERY

JANUARY 24, 2020 NORMAL SPONTANEOUS

J.B. ANN A. FRANCISCO, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
5:56 AM VAGINAL DELIVERY

FEBRUARY 17,
NORMAL SPONTANEOUS
2020 K.R.B. ANN A. FRANCISCO, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
VAGINAL DELIVERY
4:44 AM

Noted by: EDRELYN A. VENTURANZA, RN Approved by: RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN, LPT

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. 0202539 Valid Until: JUNE 29, 2024 Dean, PRC I.D No. 0348415 Valid Until: APRIL 8, 2023

Date document is signed: Time: Date document is signed: Time:

Please specify Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Specify Highest Nursing Degree Earned: DOCTOR OF PHILOSOPHY IN EDUCATION
 St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185 ODC Form 1B
Website: http://www.sachri.edu.ph ASSISTED Delivery
Government Recognition No. 012; Series of 1982 – July 6, 1981 FORM
(STRICTLY NO DESIGNATES)

ACTUAL DELIVERY in ROXAS CITY HEALTH BIRTHING CLINIC

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: MICHELLE BURGOS ALOVERA

Patient’s INITIAL only PROCEDURE D.R. Nurse On Duty

Date Performed Case Number SUPERVISED BY
and
PERFORMED (Name and Signature)
Clinical Instructor
(not applicable for (If Midwife on Duty,
Time of Delivery Birthing/ Lying-in Name and Signature
ASSISTED DELIVERY Signature not Required)
Clinics/Homes)

JANUARY 15, 2020 NORMAL SPONTANEOUS VAGINAL RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN

M.D. ANN A. FRANCISCO, RN
3:30 PM DELIVERY

JANUARY 22, 2020 NORMAL SPONTANEOUS VAGINAL RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN

M.C. ANN A. FRANCISCO, RN
4:30 AM DELIVERY

FEBRUARY 2, 2020 NORMAL SPONTANEOUS VAGINAL RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN

R.A. ANN A. FRANCISCO, RN
2:00 AM DELIVERY

Noted by: EDRELYN A. VENTURANZA, RN Approved by: RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN, LPT
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No. 0202539 Valid Until: JUNE 29, 2024 Dean, PRC I.D No. 0348415 Valid Until: APRIL 8, 2023
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Specify Highest Nursing Degree Earned: DOCTOR OF PHILOSOPHY IN EDUCATION

(STRICTLY NO DESIGNATES)
 St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://www.sachri.edu.ph ODC Form 1C
Government Recognition No. 012; Series of 1982 – July 6, 1981 CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in ST. ANTHONY COLLEGE OF ROXAS CITY INC. (HOSPITAL)
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: MICHELLE BURGOS ALOVERA

Patient’s INITIAL only Immediate Newborn Cord Care D.R. Nurse On Duty
Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(not applicable for Birthing/ Indicate where performed e.g. (If Midwife on Duty,
Time of Delivery Name and Signature
Lying-in Clinics/Homes) D.R., Nursery, NICU, or Home Signature not Required)
OCTOBER 16, 2019
BABY BOY C. DELIVERY ROOM ANN A. FRANCISCO, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
10:56 AM

JANUARY 24, 2020

BABY BOY B. DELIVERY ROOM ANN A. FRANCISCO, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
5:12 AM

FEBRUARY 3, 2020 RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN

BABY GIRL B. DELIVERY ROOM ANN A. FRANCISCO, RN
1:42 PM

Noted by: EDRELYN A. VENTURANZA, RN Approved by: RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN, LPT

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. 0202539 Valid Until: JUNE 29, 2024 Dean, PRC I.D No. 0348415 Valid Until: APRIL 8, 2023

Date document is signed: Time: Date document is signed: Time:

Please specify Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Specify Highest Nursing Degree Earned: DOCTOR OF PHILOSOPHY IN EDUCATION
 St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://www.sachri.edu.ph
Government Recognition No. 012; Series of 1982 – July 6, 1981

ODC Form 2A
O.R. SCRUB FORM
(STRICTLY NO DESIGNATES) Major

SURGICAL SCRUB in ST. ANTHONY COLLEGE OF ROXAS CITY INC. (HOSPITAL)

Hospital, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: MICHELLE BURGOS ALOVERA

Date Performed Patient’s INITIAL only O.R. Nurse On Duty SUPERVISED BY

and
SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
Time Started Case Number
PERFORMED Name and Signature

APRIL 27, 2022 V.B. COLONOSCOPY WITH SNARE

8:29 AM 323638 POLYPECTOMY MARY JOY A. ARTATES, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN

PHACOEMULSIFICATION WITH
APRIL 29, 2022 M.A.B.
POSTERIOR CHAMBER INTRAOCULAR ANDREA MAY I. MEDINA. RN MA. DAREN D. DE JUSTO, RN, MAN
2:45 PM 323686
LENS INSERTION AT RIGHT EYE

MAY 24, 2022 B.B. OPEN REDUCTION INTERNAL

ANGELICA MAE M. BARNES, RN MA. DAREN D. DE JUSTO, RN, MAN
5:34 PM 1182018136 FIXATION PLATING LEFT CLAVICLE

Noted by: EDRELYN A. VENTURANZA, RN Approved by: RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN, LPT

(Print Name and Signature) (Print Name and Signature)

 St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://www.sachri.edu.ph
Government Recognition No. 012; Series of 1982 – July 6, 1981

Clinical Coordinator, PRC I.D No. 0202539 Valid Until: JUNE 29, 2024 Dean, PRC I.D No. 0348415 Valid Until: APRIL 8, 2023

Date document is signed: Time: Date document is signed: Time:

Please specify Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Specify Highest Nursing Degree Earned: ODCINForm
DOCTOR OF PHILOSOPHY 2B
EDUCATION

O.R. CIRCULATING FORM

(STRICTLY NO DESIGNATES)

SURGICAL SCRUB in ST. ANTHONY COLLEGE OF ROXAS CITY, INC. (HOSPITAL)

Hospital, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: MICHELLE BURGOS ALOVERA

Date Performed Patient’s INITIAL only O.R. Nurse On Duty SUPERVISED BY

and
SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
Time Started Case Number
PERFORMED Name and Signature

PHACOEMULSIFICATION WITH
MAY 5, 2022 S.Y. POSTERIOR CHAMBER
12:58 PM 323769 INTRAOCULAR LENS INSERTION AT ANDREA MAY I. MEDINA, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
LEFT EYE
MAY 6, 2022 J.A.
TOTAL THYROIDECTOMY
7:44 AM 1182018101 ANGELICA MAE M. BARNES, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN

JUNE 2, 2022 G.J.

COLONOSCOPY WITH BIOPSY JOPAZ E. TAN, RN RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN
9:17 AM 242358
 St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://www.sachri.edu.ph
Government Recognition No. 012; Series of 1982 – July 6, 1981

Noted by: EDRELYN A. VENTURANZA, RN Approved by: RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN, LPT

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. 0202539 Valid Until: JUNE 29, 2024 Dean, PRC I.D No. 0348415 Valid Until: APRIL 8, 2023

Date document is signed: Time: Date document is signed: Time:

Please specify Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Specify Highest Nursing Degree Earned: DOCTOR OF PHILOSOPHY IN EDUCATION

(STRICTLY NO DESIGNATES) ODC Form 1C

CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in ROXAS CITY HEALTH BIRTHING CLINIC

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student: KILAH LUCIEN CHIVA MONTANEJOS

Patient’s INITIAL only Immediate Newborn Cord Care D.R. Nurse On Duty
Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(not applicable for Birthing/ Lying-in Indicate where performed e.g. D.R., (If Midwife on Duty,
Time of Delivery Name and Signature
Clinics/Homes) Nursery, NICU, or Home Signature not Required)

OCTOBER 08, 2019 MABEL ALONA A.

BABY GIRL D. DELIVERY ROOM ANN A. FRANCISCO, RN
8:44 PM MACAHILIG, RN, MSN
 St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: http://www.sachri.edu.ph
Government Recognition No. 012; Series of 1982 – July 6, 1981

OCTOBER 09, 2019 MABEL ALONA A.

BABY BOY A. DELIVERY ROOM ANN A. FRANCISCO, RN
1:38 PM MACAHILIG, RN, MSN

Noted by: EDRELYN A. VENTURANZA, RN Approved by: RUBILYN A. BULQUERIN-SUMAYLO, PhD, RN, LPT

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. 0202539 Valid Until: JUNE 29, 2024 Dean, PRC I.D No. 0348415 Valid Until: APRIL 8, 2023

Date document is signed: Time: Date document is signed: Time:

Please specify Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Specify Highest Nursing Degree Earned: DOCTOR OF PHILOSOPHY IN EDUCATION

(STRICTLY NO DESIGNATES)