You are on page 1of 7

PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY

PRC FORM No. 106
(Revised January 2011)

Record of Actual Deliveries Handled
Record of Actual Delivery Handled

Please chec(CONTINUED NEXT PAGE)___________Health
and Allied Medical Sciencesicense Number:
___________________________
Expiry Date : _____k if

Name of Applicant: ________________________________________
La Union Campus

applicant
is: Memorial State University; South
School: Don Mariano
Marcos
Graduate Midwife

Registered Nurse

Name and Address of Patient Case No Complete Diagnosis (Gravida. Address of Facility & Contact Number Check if Home Delive ry Supervised by Printed Name and Contact No. Position / Designatio n Signature License No / Expiry Date 1 2 3 4 5 6 7 8 9 10 11 (continued next page) 12 13 . Para) Date & Time Performed Full Name.

Para) Date & Time Performed Full Name. __________________________ issued at ______________________________ on CERTIFIED CORRECT: _______________________________. Affix Administering Officer or Notary Public Documentary Stamp Signature: __________________________________________________ Date: ___________________________ Printed Name: OFELIA O. Position / Designatio n Signature License No / Expiry Date 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 ______________________________________. Address of Facility & Contact Number Check if Home Delive ry Supervised by Printed Name and Contact No. Affiant exhibiting to me his/her Residence Certificate No. VALDEHUEZA Designation: Director-Institute of Community Health and Allied Medical Sciences License Number: 0108054 Expiry Date : Renewal on process mito 2011 .Name and Address of Patient Case No Complete Diagnosis (Gravida.

School: Don Mariano Graduate Midwife Registered Nurse . 107 (Revised January 2011) Record of Actual Deliveries Handled Record of Actual Suturing of Lacerations Handled Please chec(CONTINUED NEXT PAGE)___________Health and Allied Medical Sciencesicense Number: ___________________________ Expiry Date : _____k if Name of Applicant: ________________________________________ South La Union Campus applicant is: Marcos Memorial State University.PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY PRC FORM No.

1993. Affix Administering Officer or Notary Public Documentary Stamp Signature: __________________________________________________ Date: ___________________________ Printed Name: OFELIA O. 100 s 1993. VALDEHUEZA Designation: Director-Institute of Community Health and Allied Medical Sciences License Number: 0108054 Expiry Date : Renewal on process mito 2011 . Position / Designatio n Signature License No / Expiry Date 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.Name and Address of Patient Case No Complete Diagnosis (Gravida. dated December 1. Address of Facility & Contact Number Check if Home Delive ry Supervised by Printed Name and Contact No. __________________________ issued at ______________________________ on CERTIFIED CORRECT: _______________________________. SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. Para) Date & Time Performed Full Name.

PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY PRC FORM No. 107-A (Revised January 2011) Record of Actual Deliveries Handled Record of Actual Intravenous Insertions Please chec(CONTINUED NEXT PAGE)___________Health and Allied Medical Sciencesicense Number: ___________________________ Expiry Date : _____k if Name of Applicant: ________________________________________ South La Union Campus applicant is: Marcos Memorial State University. School: Don Mariano Graduate Midwife Registered Nurse .

__________________________ issued at ______________________________ on CERTIFIED CORRECT: _______________________________. Position / Designatio n Signature License No / Expiry Date 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. dated December 1.Name and Address of Patient Case No Complete Diagnosis (Gravida. Affiant exhibiting to me his/her Residence Certificate No. Address of Facility & Contact Number Check if Home Delive ry Supervised by Printed Name and Contact No. 100 s 1993. Affix Administering Officer or Notary Public Documentary Stamp Signature: __________________________________________________ Date: ___________________________ Printed Name: OFELIA O. SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Para) Date & Time Performed Full Name. 1993. VALDEHUEZA Designation: Director-Institute of Community Health and Allied Medical Sciences License Number: 0108054 Expiry Date : Renewal on process mito 2011 .