PRC FORM No.

106
(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY

Record of Actual Delivery Handled

Please check if applicant is: Graduate Midwife Name of Applicant: ________________________________________
Name and Address of Patient 1 2 3 4 5 6 7 8 9 10 Case No
Complete Diagnosis (Gravida, Para)
Date & Time Performed

Registered Nurse

School: Don Mariano Marcos Memorial State University; South La Union Campus
Full Name, Address of Facility & Contact Number
Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

(continued next page)

Name and Address of Patient 11

Case No

Complete Diagnosis (Gravida, Para)

Date & Time Performed

Full Name, Address of Facility & Contact Number

Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

12

13

14

15

16

17

18

19

20

Note:

(1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.
CERTIFIED CORRECT:

Affix
Administering Officer or Notary Public Documentary Stamp
to be posted on the last page

Signature: __________________________________________________ Date: ___________________________ Printed Name: OFELIA O. VALDEHUEZA Designation: Director-Institute of Community Health and Allied Medical Sciences License Number: 0108054 Expiry Date : Renewal on process mito 2011

PRC FORM No. 107

(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY

Record of Actual Suturing of Lacerations Handled

Please check if applicant is: Graduate Midwife Name of Applicant: ________________________________________
Name and Address of Patient 1 2 3 4 5 Note: (1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor (2) For registered midwives / Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on Intravenous Insertions to the Board pursuant to Board Resolution No. 100 s 1993, dated December 1, 1993. Case No
Complete Diagnosis (Gravida, Para)
Date & Time Performed

Registered Nurse

School: Don Mariano Marcos Memorial State University; South La Union Campus
Full Name, Address of Facility & Contact Number
Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.
CERTIFIED CORRECT:

Affix
Administering Officer or Notary Public Documentary Stamp
to be posted on the last page

Signature: __________________________________________________ Date: ___________________________ Printed Name: OFELIA O. VALDEHUEZA Designation: Director-Institute of Community Health and Allied Medical Sciences License Number: 0108054 Expiry Date : Renewal on process mito 2011

PRC FORM No. 107-A

(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY

Record of Actual Intravenous Insertions

Please check if applicant is: Graduate Midwife Name of Applicant: ________________________________________
Name and Address of Patient 1 2 3 4 5 Note: (1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor (2) For registered midwives / Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on Suturing of Perineal lacerations to the Board pursuant to Board Resolution No. 100 s 1993, dated December 1, 1993. Case No
Complete Diagnosis (Gravida, Para)
Date & Time Performed

Registered Nurse

School: Don Mariano Marcos Memorial State University; South La Union Campus
Full Name, Address of Facility & Contact Number
Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.
CERTIFIED CORRECT:

Affix
Administering Officer or Notary Public Documentary Stamp
to be posted on the last page

Signature: __________________________________________________ Date: ___________________________ Printed Name: OFELIA O. VALDEHUEZA Designation: Director-Institute of Community Health and Allied Medical Sciences License Number: 0108054 Expiry Date : Renewal on process mito 2011