PROFESSIONAL REGULATION COMMISSION

PRC FORM No. 106

Manila
(Revised January 2011) BOARD OF MIDWIFERY
Record of Actual Delivery Handled
Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: ________________________________________ School: Don Mariano Marcos Memorial State University; South La Union Campus

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

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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 Signature: __________________________________________________ Date: ___________________________

Documentary Stamp Printed Name: OFELIA O. VALDEHUEZA
Administering Officer or Notary Public to be posted on the last page Designation: Director-Institute of Community Health and Allied Medical Sciences
License Number: 0108054 Expiry Date : Renewal on process mito 2011
 PRC FORM No. 107 PROFESSIONAL REGULATION COMMISSION
Manila
(Revised January 2011) BOARD OF MIDWIFERY
Record of Actual Suturing of Lacerations Handled
Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: ________________________________________ School: Don Mariano Marcos Memorial State University; South La Union Campus

Check if Supervised by
Case Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient (Gravida, Para) Performed & Contact Number
Home Printed Name and Position / License No /
No Delivery Signature
Contact No. Designation Expiry Date
1

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.

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

Affix Signature: __________________________________________________ Date: ___________________________

Documentary Stamp Printed Name: OFELIA O. VALDEHUEZA
Administering Officer or Notary Public to be posted on the last page 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 PROFESSIONAL REGULATION COMMISSION
Manila
(Revised January 2011) BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions
Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: ________________________________________ School: Don Mariano Marcos Memorial State University; South La Union Campus

Check if Supervised by
Case Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient (Gravida, Para) Performed & Contact Number
Home Printed Name and Position / License No /
No Delivery Signature
Contact No. Designation Expiry Date
1

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.

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

Affix Signature: __________________________________________________ Date: ___________________________

Documentary Stamp Printed Name: OFELIA O. VALDEHUEZA
Administering Officer or Notary Public to be posted on the last page Designation: Director-Institute of Community Health and Allied Medical Sciences
License Number: 0108054 Expiry Date : Renewal on process mito 2011