PRC FORM No.

106 (Revised October 2010)

Republic of the Philippines

Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Deliveries Handled Please Check:
Graduate Midwife Name of Applicant: _______________________________________________________________ Case No. Complete diagnosis (gravida_para_) Date & Time Performed Registered Nurse

School: _______________________________________________________________________ CHECK IF HOME DELIVERY SUPERVISED BY: PRINTed name & contact No. Position/ Designation Signature License No./ Expiration date

NAME and address OF PATIENT 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Full name, address of facility & contact number

16. Affiant exhibiting to me his/her Residence Certificate No. 17.NAME and address OF PATIENT 11.:_____________ Expiry Date:______________ Affix ________________________________ Administering Officer or Notary Public Documentary Stamp (to be posted on the last page) . Complete diagnosis (gravida_para_) Date & Time Performed Full name. 12. ____________ issued at _______________________ on ____________________. 14. 20. Position/ Designation Signature License No. 2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. CERTIFIED CORRECT: Signature: ___________________ Date: ___________ Printed Name: ________________________________ Designation:__________________________________ Lic. 13. 18. Case No. 7392. SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. No. 15. 19. address of facility & contact number CHECK IF HOME DELIVERY SUPERVISED BY: PRINTed name & contact No./ Expiration date NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.

address of facility & contact number 1. 4. Position/ Designation Signature License No. 3. Complete diagnosis (gravida_para_) Date & Time Performed Registered Nurse School: _______________________________________________________________________ CHECK IF HOME DELIVERY SUPERVISED BY: PRINTed name & contact No./ Expiration date NAME and address OF PATIENT Full name. 107 (Revised October 2010) Republic of the Philippines Professional Regulation Commission Lucena City BOARD OF MIDWIFERY Record of Actual Repair of Perineal Lacerations Please Check: Graduate Midwife Name of Applicant: _______________________________________________________________ Case No.PRC FORM No. 2. 5. (See back page) .

PRC FORM No. 4.:_____________ Expiry Date:______________ Affix ________________________________ Administering Officer or Notary Public Documentary Stamp (to be posted on the last page) . Complete diagnosis (gravida_para_) Date & Time Performed School: _______________________________________________________________________ CHECK IF HOME DELIVERY SUPERVISED BY: PRINTed name & contact No. 5. 3. address of facility & contact number 1. 107-A (Revised October 2010) Republic of the Philippines Professional Regulation Commission Lucena City BOARD OF MIDWIFERY Record of Actual Intravenous Insertions Name of Applicant: _______________________________________________________________ Case No./ Expiration date NAME and address OF PATIENT Full name. ____________ issued at _______________________ on ____________________. 2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R. Position/ Designation Signature License No. No. Affiant exhibiting to me his/her Residence Certificate No. SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. 2. CERTIFIED CORRECT: Signature: ___________________ Date: ___________ Printed Name: ________________________________ Designation:__________________________________ Lic. NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor. 7392.A.

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