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 Registered Nurse

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

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

Supervised by Printed Name and Contact No. Position / Designation Signature License No / Expiry Date

(continued next page)

Name and Address of Patient 11 12 13 14 15 16 17 18 19 20 Note:

Case No

Complete Diagnosis (Gravida, Para)

Date & Time Performed

Full Name, Address of Facility & Contact Number

Check if Home Delivery

Supervised by Printed Name and Contact No. Position / Designation Signature License No / Expiry Date

(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)

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

PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY

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)

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

PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY

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