PRC FORM No.

106
Republic of the Philippines
(Revised October 2010)
Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Deliveries Handled

Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

Date & CHECK SUPERVISED BY:

Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.
 Date & CHECK SUPERVISED BY:
Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.
2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. 7392.

SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. Affiant

exhibiting to me his/her Residence Certificate No. ____________ issued at _______________________ on ____________________.
CERTIFIED CORRECT:

Signature: ___________________ Date: ___________

Affix Printed Name: ________________________________
________________________________ Documentary Stamp Designation:__________________________________
(to be posted on the last page)
Administering Officer or Notary Public Lic. No.:_____________ Expiry Date:______________
 PRC FORM No. 107
Republic of the Philippines
(Revised October 2010)
Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Repair of Perineal Lacerations

Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

Date & CHECK SUPERVISED BY:

Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date

1.

2.

3.

4.

5.

(See back page)

 PRC FORM No. 107-A
Republic of the Philippines
(Revised October 2010)
Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions

Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

Date & CHECK SUPERVISED BY:

Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date

1.

2.

3.

4.

5.

NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.
2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. 7392.

SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. Affiant

exhibiting to me his/her Residence Certificate No. ____________ issued at _______________________ on ____________________.
CERTIFIED CORRECT:

Signature: ___________________ Date: ___________

Affix Printed Name: ________________________________
________________________________ Documentary Stamp Designation:__________________________________
(to be posted on the last page)
Administering Officer or Notary Public Lic. No.:_____________ Expiry Date:______________