PRC FORM No.

106 PROFESSIONAL REGULATION COMMISION

(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Please Check:
Graduate Midwife  Registered Nurse

Name of Applicant: JHAN ROBERT RAIE ESTABAYA IRANG School: OUR LADY OF LOURDES COLLEGE FOUNDATION

Check Supervised by:

Date & Full Name,
Name and Address of Case Complete Diagnosis if License No./
Time Address of Facility Printed Name & Position/
Patient No. (Gravida_Para_) Home Signature Expiration
Performed & Contact Number Contact No. Designation
Del. Date
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

(Continued at the Back)

 Check Supervised by:
Date & Full Name,
Name and Address of Case Complete Diagnosis if License No./
Time Address of Facility Printed Name & Position/
Patient No. (Gravida_Para_) Home Signature Expiration
Performed & Contact Number Contact No. Designation
Del. Date
11.

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 CERTIFIED CORRECT:
____________________ at _____________________Affiant
exhibiting to me his/her Residence Certificate No. _______________
issued at ________________________ on ___________________.
Signature: ______________________ Date: ____________
Affix Printed Name: o
Documentary Stamp Designation: Principal/Asst. Dean/Clinical Coordinator o
(to be posted on the last page) License Number: Expiry Date:
 PRC FORM No. 107 PROFESSIONAL REGULATION COMMISION
(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Laceration
Please Check:
Graduate Midwife  Registered Nurse

Name of Applicant: JHAN ROBERT RAIE ESTABAYA IRANG School: OUR LADY OF LOURDES COLLEGE FOUNDATION

Check Supervised by:

Date & Full Name,
Name and Address of Case Complete Diagnosis if License No./
Time Address of Facility Printed Name & Position/
Patient No. (Gravida_Para_) Home Signature Expiration
Performed & Contact Number Contact No. Designation
Del. Date
1.

2.

3.

4.

5.

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

2) Registered Midwives/Clinical Instructors who supervise student midwives and affix their signature in this Form must present Certificate of Training on
Suturing of Perineal lacerations to the Board pursuant to Board Resolutions No. 100, Series of 1993, dated December 1,1993

(See back page)

 PRC FORM No. 107-A PROFESSIONAL REGULATION COMMISION
(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions

Name of Applicant: JHAN ROBERT RAIE ESTABAYA IRANG School: OUR LADY OF LOURDES COLLEGE FOUNDATION

Check Supervised by:

Date & Full Name,
Name and Address of Case Complete Diagnosis if License No./
Time Address of Facility Printed Name & Position/
Patient No. (Gravida_Para_) Home Signature Expiration
Performed & Contact Number Contact No. Designation
Del. Date
1.

2.

3.

4.

5.

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

2) Registered Midwives/Clinical Instructors who supervise student midwives and affix their signature in this Form must present Certificate of Training on
Suturing of Perineal lacerations to the Board pursuant to Board Resolutions No. 100, Series of 1993, dated December 1,1993

SUBSCRIBED AND SWORN To before me this CERTIFIED CORRECT:

____________________ at _____________________Affiant
exhibiting to me his/her Residence Certificate No. _______________
issued at ________________________ on ___________________. Signature: ______________________ Date: ____________
Affix Printed Name:
Documentary Stamp Designation: Principal/Asst. Dean/Clinical Coordinator o
(to be posted on the last page)
License Number: Expiry Date: