PRC FORM No.

106 PROFESSIONAL REGULATION COMMISSION

(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handle
Please Check:
∕ Graduate Midwife Registered nurse

Name of Applicant: ESCABARTE, ALEXIS COLLANTES School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
Name and Address of Case No. Complete Diagnosis Date and Full Name, Address of Facility Check if
Patient ( Gravida_Para_) Time & Contact Number Home Del. Supervised By:
Performed Printed Name & Position/ License No./
Contact No. Designation Signature Exp. Date
1.Danica Mae Amata Padua 2022-2242 G2P2(2002) June 11,2022 Rural Health Unit
Pinaglabanan, Goa,Camarines Sur Danica,20 y/o,(G2P2),PU,AOG-39 8:27 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days.Cephalic.Delivered to a live Contact No#.0950-534-2377 09101868007 Clinical Instructor Exp.03/29/24
Bb.Girl via NSD.APGAR 9.Wt.2050 grams.
2.Princess Delos Santos Aquino 2022-2243 G4P4(4004) June 11,2022 Rural Health Unit
Buyo,Goa,Camarines Sur Princess,28 y/o,(G4P4),PU,AOG 39 10:30 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/6days.Cephalic.Delivered to a live Clinical Instructor
Bb.Girl via NSD.APGAR 9.Wt.2550grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

3.Grace Asor Oliquino 2022-2244 G4P4(4004) June 12,2022 Rural Health Unit
Hiwacloy,Goa,Camarines Sur Grace,29 y/o,(G4P4),PU,AOG-39 2:06 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days.Cephalic.Delivered to a live Clinical Instructor
Bb.Girl via NSD.APGAR 8.Wt.3050 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

4.Melanie Agnas Palilar 2022-2245 G4P4(4004) June 14,2022 Rural Health Unit
San Jose St.,Goa,Camarines Sur Melanie,38y/o,(G4P4),PU,AOG-39 7:59 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/1day.Cephalic.Delivered to a live Clinical Instructor
Bb.Boy via NSD.APGAR 9.Wt.2045 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

5.Rosalie Bernal Sorlao 2022-2246 G3P3(3003) June 15,2022 Rural Health Unit
Buyo,Goa,Camarines Sur Rosalie,29 y/o,(G2P2),PU,AOG-39 6:02 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/3days.Cephalic.Delivered to a live Clinical Instructor
Bb.Girl via NSD.APGAR 8.Wt.3080grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

6.Jinky Deleña Rayala 2022-2198 G3P2(3012) May 14,2022 Rural Health Unit
San Benito,Goa,Camarines Sur Jinky,33y/o,(G3P2),PU,AOG-39 8:26 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/5days.Cephalic.Delivered to a live Clinical Instructor
Bb.Boy via NSD.APGAR 9.Wt.3045 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

7.Dolores Orolfo Camacho 2022-2202 G4P4(4004) May 20,2022 Rural Health Unit
L.Pan,Goa,CamarinesSur Dolores,29 y/o,(G4P4),PU,AOG-39 4:23 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days.Cephalic.Delivered to a live Clinical Instructor
Bb.Boy via NSD.APGAR 10.Wt.2050 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

8.Tempo Delos Santos Belleza 2022-2173 G3P3(3003) May 1,2022 Rural Health Unit Lic.#0174893
Gimaga,Goa,Camarines Sur Tempo,30 y/o,(G3P3),PU,AOG 38 12:07 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez
weeks/4days.Cephalic.Delivered to a live Clinical Instructor Exp.03/29/24
Bb.Boy via NSD.APGAR 9.Wt.3050 grams Contact No#.0950-534-2377 09101868007

9.Ma.Eloisa Camba Tubale 2022-2182 G2P2(2002) May 6,2022 Rural Health Unit
Siruma,Camarines Sur Ma.Eloisa,27 y/o,(G2P2),PU,AOG39 11:00 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days.Cephalic.Delivered to a live Clinical Instructor
Bb.Girl via NSD.APGAR 9.Wt.3450 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

10.Lovelyn Rodriguez Siruma 2022-2185 G4P4(4004) May 7,2022 Rural Health Unit
Aroro,Goa,Camarines Sur Lovelyn,22 y/o,(G4P4),PU,AOG-40 9:40 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days.Cephalic.Delivered to a live Clinical Instructor
 Bb.Boy via NSD.APGAR 9.Wt.3845 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

11.Mariane Buentiempo Pedro 2022-2194 G3P3(3003) May 12,2022 Rural Health Unit
Halawig-gogon,Goa,Camarines Sur Mariane, 26 y/o,(G3P3),PU,AOG-38 7:32 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/5days.Cephalic.Delivered to a live Clinical Instructor
Bb.Girl via NSD.APGAR 8.Wt.2840 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

12.Josie Sadia Briguera 2022-2197 G3P3(3003) May 14,2022 Rural Health Unit
San Juan Josie,21y/o,(G3P3),PU,AOG-38 6:04 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
Evangelista,Goa,Camarines Sur weeks/5days.Cephalic.Delivered to a live Clinical Instructor
Bb.Boy via NSD.APGAR 9.Wt.3550 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

13.Jin Arwin Shane Panganiban 2022-2318 G2P2(2002) July 26,2022 Rural Health Unit
Buyo,Goa,Camarines Sur Jin,22 y/o,(G2P2),PU,AOG-38 11:48 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/4days.Cephalic.Delivered to a live
Bb.Girl via NSD.APGAR 9.Wt.2050 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

14.Ivie Peña Peda 2022-2184 G4P4(4004) May 21,2022 Rural Health Unit
Telegrafo,San Jose,Camarines Sur Ivie,30 y/o,(G4P4),PU,AOG-40 8:04 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/4days.Cephalic.Delivered to a live
Bb.Girl via NSD.APGAR 9.Wt.2080 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

15.Marilyn Fermiza Serrano 2022-2212 G4P3(4013) May 22,2022 Rural Health Unit
Tabgon,Goa,Camarines Sur Marilyn,31 y/o,(G4P3),PU,AOG-39 12:46 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/5days.Cephalic.Delivered to a live
Bb.Girl via NSD.APGAR 8.Wt.3545 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

16.Jemilyn Sernitse Pasacay 2022-2218 G3P3(3003) May 26,2022 Rural Health Unit
San Sebastian,Lagonoy,Camarines Jemilyn,25 y/o,(G3P3),PU,AOG-38 3:53 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
Sur weeks/4days.Cephalic.Delivered to a live
Bb.Boyl via NSD.APGAR 10.Wt.2050 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

17.Maricel Boñaga Penilla 2022-2219 G2P2(2002) May 26,2022 Rural Health Unit
Tinawagan,Tigaon,Camarines Sur Maricel,21 y/o,(G2P2),PU,AOG-39 4:48 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/4days.Cephalic.Delivered to a live
Bb.Boy via NSD.APGAR 9.Wt.3550 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

18.Janet Diaz Brequillo 2022-2224 G4P4(4004) May 28,2022 Rural Health Unit
Matacla,Goa,Camarines Sur Janet,29 y/o,(G4P4),PU,AOG-40 8:26 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/1day.Cephalic.Delivered to a live
Bb.Boy via NSD.APGAR 7.Wt.3050 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

19.Baby Jane Pederico Pana 2022-2186 G4P4(4004) May 29, 2022 Rural Health Unit
Payatan,Goa,Camarines Sur Baby Jane,30 y/o,(G4P4),PU,AOG-38 12:07 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/4days.Cephalic.Delivered to a live
Bb.Girl via NSD.APGAR 9.Wt.3803 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

20.Lani Dela Cruz 2022-2221 G4P4(4004) May 29, 2022 Rural Health Unit
Catagbacan,Goa,Camarines Sur Lani,30 y/o,(G2P2),PU,AOG-39 6:38 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Clinical Instructor Lic.#0174893
weeks/5days.Cephalic.Delivered to a live
Bb.Girl via NSD.APGAR 10.Wt.2650 grams Contact No#.0950-534-2377 09101868007 Exp.03/29/24

Note: 1.) For graduate midwives: Supervision must be by qualified faculty/ clinical instructor.
2.) Registered Midwives/ Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries
Handled to the Board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993.

SUBSCRIBED AND SWORN, to before me this

_________________ at __________________ Affiant CERTIFIED CORRECT:
Exhibiting to me his/her Residence Certificate No.________ AFFIX
Issued at _____________ on _______________ Documentary Stamp
(to be posted on the page) Signature: ____________________ Date _____________
Printed Name: KRISTYL JOY F. BERMIDO RN,RM,MAN.
Designation:OIC/ Principal of Midwifery
License Number:RN-0443046 Expiry Date: 12/11/2024
RM-0148086 Expiry Date: 12/11/2024

PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION

 (Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Laceration

Please Check:

∕ Graduate Midwife Registered nurse

Name of Applicant: ESCABARTE, ALEXIS COLLANTES School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
Name and Address of Case No. Complete Date and Time Full Name, Address of Check if
Patient Diagnosis Performed Facility & Contact Home Del. Supervised By:
( Gravida_Para_) Number Printed Name & Position/ License
Contact No. Designation Signature No./ Exp.
Date
1. Joan Ignacio Ramos 2022-2112 G2P2(2002) Rural Health Unit
Buyo,Goa, Camarines Sur Joan,25y/o,G2P2 PU,39 March 19,2022 Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days,cephalic in 9:59 PM 09101868007 Clinical Instructor Exp.03/29/24
labor,delivered NSD to a live Contact No#.0950-534-2377
baby girl,APGAR- 9,BW-3080
grams,suturing done.
2.Analyn Santos Velasco 2022-2114 G3P3(3003) March 20,2022 Rural Health Unit
Tabgon,Goa,Camarines Sur Analyn,30 y/o,G3P3 PU,39 3:30 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/1days,cephalic in 09101868007 Clinical Instructor Exp.03/29/24
labor,delivered NSD to a live Contact No#.0950-534-2377
baby girl,APGAR- 9,BW-2550
grams, suturing done.
3.Kyne Renz Belleca Brizuela 2022-2119 G2P2(2002) March 20,2022 Rural Health Unit
Catagbacan,Goa,Camarines Sur Kyne,21y/o,G2P2 PU,38 3:25 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/5days,cephalic in 09101868007 Clinical Instructor Exp.03/29/24
labor,delivered NSD to a live Contact No#.0950-534-2377
baby girl,APGAR- 9,BW-2560
grams,suturing done
4.Patricia Porferia 2022-2129 G2P2(2002) March 26,2022 Rural Health Unit
Catalotoan,Goa,Camarines Sur Patricia,21y/o,G2P2 PU,39 1:12 PM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/1days,cephalic in 09101868007 Clinical Instructor Exp.03/29/24
labor,delivered NSD to a live Contact No#.0950-534-2377
baby boy,APGAR-9,BW-2850
grams,suturing done.
5.Julie Ann Padillo Solo 2022-2147 G2P2(2002) April 05,2022 Rural Health Unit
Tabgon,Goa,Camarines Sur Julie Ann,20y/o,G2P2 PU,38 11:51 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
weeks/4days,cephalic in 09101868007 Clinical Instructor Exp.03/29/24
labor,delivered NSD to a live Contact No#.0950-534-2377
baby girl,APGAR- 9,BW-3503
grams,suturing done.
Note: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.
2.) Registered Midwives/ Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries Handled to
the Board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993

PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION

(Revised October 2010) Manila
 BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions
Please Check:

√ Graduate midwife Registered nurse

Name of Applicant: ESCABARTE, ALEXIS COLLANTES School:FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
Name and Address of Case No. Complete Date and Time Full Name, Address of Check if
Patient Diagnosis Performed Facility & Contact Home Del. Supervised By:
( Gravida_Para_) Number Printed Name & Position/ License
Contact No. Designation Signature No./ Exp.
Date
1. Marissa Dela Torre Darilay G4P4(4004) April 03,2022 Rural Health Unit
Payatan,Goa, Camarines Sur 2022-2142 Marissa,29y/o,G4P4(4004), 4:33 AM Panday St.,Goa,Camarines Sur Cyril C.Dominguez Lic.#0174893
Pregnancy uterine 40 09101868007 Clinical Instructor Exp.03/29/24
weeks,cephalic in labor Contact No#.0950-534-2377
2.Jenny Pades Olea 2022-2113 G4P4(4004) March 20,2022 Rural Health Unit Cyril C.Dominguez Lic.#0174893
Abucayan,Goa,Camarines Sur Jenny,29y/o,G4P4(4004), 1:00 AM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Exp.03/29/24
Pregnancy uterine 39
weeks,cephalic in labor. Contact No#.0950-534-2377
3.Cara Malto Triñanes 2022-2116 G4P4(4004) March 20,2022 Rural Health Unit Cyril C.Dominguez Lic.#0174893
Mampirao,San Jose,Camarines Sur Cara,29y/o,G4P4(4004), 11:04 PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Exp.03/29/24
Pregnancy uterine 39
weeks,cephalic in labor Contact No#.0950-534-2377
4.Jemina Cledera Besmonte 2022-2128 G3P3(3003) March 25,2022 Rural Health Unit Cyril C.Dominguez Lic.#0174893
Bag.Pequeño,Goa,Camarines Sur Jemina,20y/o,G3P3(3003), 2:41 PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Exp.03/29/24
Pregnancy uterine 40
weeks,cephalic in labor Contact No#.0950-534-2377
5.Michelle Corono Sierra 2022-2152 G3P3(3003) April 08,2022 Rural Health Unit Cyril C. Dominguez Lic.#0174893
Tagongtong,Goa,Camarines Sur Michelle,26y/o,G3P3(3003), 1:49PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Exp.03/29/24
Pregnancy uterine 38
weeks,cephalic in labor Contact No#.0950-534-2377
Note: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.
2.) Registered Midwives/ Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries
Handled to the Board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993.

SUBSCRIBED AND SWORN, to before me this

_________________ at __________________ Affiant CERTIFIED CORRECT:
Exhibiting to me his/her Residence Certificate No.________ AFFIX
Issued at _____________ on _______________ Documentary Stamp
(to be posted on the page) Signature:_______________ Date:_________
Printed Name:KRISTYL JOY F. BERMIDO RN,RM,MAN.
Designation:OIC/ Principal of Midwifery
License Number:RN-0443046 Expiry Date:12/11/2024
RM-0148086 ExpiryDate:12/11/2024

PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION

(Revised October 2010) Manila
 BOARD OF MIDWIFERY
Record of Actual Internal Examination
Please Check:
√ Graduate Midwife Registered nurse

Name of Applicant: ESCABARTE,ALEXIS COLLANTES School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC .

Name and Address of Case No. Complete Diagnosis Date and Full Name, Address of Check
Supervised By:
Patient ( Gravida_Para_) Time Facility & Contact if
Performe Number Home Printed Name & Position/ License No./
d Del. Contact No. Designation Signature Exp. Date
1.Joan Ignacio Ramos G2P1(2001) March 19,2022 Rural Health Unit Cyril C.Dominguez
Buyo, Goa,Camarines Sur 2022-2112 Joan,26y/o,G2P1(2001)PU,39 weeks 5:20 AM Panday St.,Goa,Camarines Sur 09101868007 Lic.#0174893
AOG,cephalic in labor,5-6 cm dilated,50% Contact No#.0950-534-2377 Clinical Instructor
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +1.
2. Jenyy Pades Olea G4P3(4003) March 20,2022 Rural Health Unit Cyril C. Dominguez Lic.#0174893
Abucayan,Goa,Camarines Sur 2022-2113 Jenny,29/o,G4P3(4003)PU,39 weeks 11:00 AM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor
AOG,cephalic in labor,6-7 cm dilated,60% Contact No#.0950-534-2377 Exp.03/29/24
effaced,BOW intact,amniotic fluid
clear,station +2.
3. Analyn Santos Velasco G3P2(3002) March 20, Rural Health Unit Cyril C.Dominguez Lic.#0174893
Tabgon,Goa, Camarines Sur 2022-2114 Analyn,30y/o,G3P2(3002)PU,40 weeks 2022 Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor
AOG,cephalic in labor,8 cm dilated,80% 2:00AM Contact No#.0950-534-2377 Exp.03/29/24
effaced,BOW intact,amniotic fluid
clear,station +3.
4. Cara Malto Triñanes G4P4(4003) March 20,2022 Rural Health Unit Cyril C.Dominguez Lic.#0174893
Mampirao,San Jose, Camarines Sur 2022-2116 Cara 29y/o,G4P3(4003)PU,39 weeks 7:04 PM Panday St.,Goa,Camarines Sur 09101868007
AOG,cephalic in labor,5-6 cm dilated,50% Contact No#.0950-534-2377 Clinical Instructor Exp.03/29/24
effaced,BOW intact,amniotic fluid
clear,station +1.
5. Kyne Renz Belleca Brizuela G2P2(2001) March 21,2022 Rural Health Unit Cyril C.Dominguez Lic.#0174893
Catagbacan,Goa, Camarines Sur 2022-2119 Kyne 21y/o,G2P1(2001)PU,39 weeks 12:25 PM Panday St.,Goa,Camarines Sur 09101868007
AOG,cephalic in labor,7-8 cm dilated,80% Contact No#.0950-534-2377 Clinical Instructor Exp.03/29/24
effaced,BOW intact,amniotic fluid
meconium,station +2.
6. Jemina Cledera Besmonte G3P2(3002) March 25,2022 Rural Health Unit Cyril C. Dominguez
Bag.Pequeño,Goa, Camarines Sur 2022-2128 Jemina,20y/o,G3P2(3002)PU,38 weeks 11:41 AM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,5-6 cm dilated,50% Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +1.
7. Jocelyn Buban Torrefiel G2P1(2001) January Rural Health Unit Cyril C.Dominguez
Scout Fuentebella,Goa, Camarines Sur 2022-2051 Jocelyn,20y/o,G2P1(2001)PU,38 weeks 30,2022 Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,5-6 cm dilated,50% 5:55 AM Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +1.
8. Cecile Cabalquinto Cano G4P3(4003) January Rural Health Unit Cyril C.Dominguez
Mampirao,San Jose,Camarines Sur 2022-2053 Cecile,31y/o,G4P3(4003)PU,39 weeks 30,2022 Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,7-8 cm dilated,80% 2:56PM Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station+2.
9.Mary Jane Estingor G4P3(4003) July 30,2022 Rural Health Unit Cyril C.Dominguez
Matacla, Goa, Camarines Sur 2022-2322 MaryJane,34y/o,G4P3(4003)PU,40 weeks 1:14 PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,8-9 cm dilated,90% Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +3.
10. Erika Villaralbo Barde G2P1(2001) February Rural Health Unit Cyril C. Dominguez Lic.#0174893
Scout Fuentebella, Goa, Camarines Sur 15530 Erika,21y/o,G2P1(2001)PU,39 weeks 10,2022 Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor
AOG,cephalic in labor,5-6 cm dilated,50% 10:10 PM Contact No#.0950-534-2377 Exp.03/29/24
effaced,BOW intact,amniotic fluid
clear,station +1.
11.Jenny Plaza Bolalaque G3P2(3002) February Rural Health Unit Cyril C. Dominguez Lic.#0174893
Pinaglabanan,Goa, Camarines Sur 11524 Jenny,37y/o,G3P2(3002)PU,38 weeks 8,2022 Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor
AOG,cephalic in labor,5-6 cm dilated,50% 7:55 AM Contact No#.0950-534-2377 Exp.03/29/24
effaced,BOW intact,amniotic fluid
 clear,station +1.
12.Mariane Buentiempo Pedro G3P2(3002) May 12,2022 Rural Health Unit Cyril C. Dominguez
Halawig-gogon, Goa, Camarines Sur 2022-2194 Mariane,26y/o,G3P2(3002)PU,38 weeks 5:30 AM Panday St.Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,6-7 cm dilated,700% Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +1.
13.Josie Sadia Briguerra G2P1(2001) May 14,2022 Rural Health Unit Cyril C. Dominguez
San Juan Evangelista,Goa, Camarines Sur 2022-2197 Josie,21y/o,G2P1(2001)PU,38 weeks 3:00 AM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,4-5 cm dilated,50% Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station 0
14. Jin Arwin Shane Panganiban G2P1(2001) July 26,2022 Rural Health Unit Cyril C. Dominguez
Buyo, Goa, Camarines Sur 2022-2318 Jin,22y/o,G2P1(2001)PU,38 weeks 7:00 AM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,5-6 cm dilated,50% Contact No#.0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +1

15. Ivie Peña Peda G4P3(4003) May 21,2022 Rural Health Unit Cyril C.Dominguez Lic.#0174893
Telegrafo,Goa, Camarines Sur 2022-2184 Ivie,30y/o,G4P3(4003)PU,39 weeks 6:03 PM Panday St.,Goa, Camarines Sur 09101868007 Clinical Instructor
AOG,cephalic in labor,7-8 cm dilated,80% Contact No#.0950-534-2377 Exp.03/29/24
effaced,BOW intact,amniotic fluid
meconium,station +2.

16.Sinening Flores Coriaje G4P3(4003) May 30,2022 Rural Health Unit Cyril C.Dominguez
Tabgon, Goa, Camarines Sur 2022-2225 Sinening,30y/o,G4P3(4003)PU,40 weeks 3:17 PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,7-8 cm dilated,80% Contact No.#0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +2.
17.Glenzel Vales Nazareno G3P2(3002) May 31,2022 Rural Health Unit Cyril C. Dominguez
Panagan, Lagonoy, Camarines Sur 2022-2226 Glenzel,30y/o,G3P2(3002)PU,39 weeks 11:00 PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,6-7 cm dilated,70% Contact No.#0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
meconium,station +1.
18. Marilyn Fermiza Serrano G4P1(4011) May 22,2022 Rural Health Unit Cyril C. Dominguez
Tabgon, Goa, Camarinessur 2022-2212 Marilyn,31y/o,G4P1(4011)PU,38 weeks 10:30 PM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,7-8 cm dilated,80% Contact No.#0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
meconium,station +2.
19.Jemilyn Senitse Pasacay G4P3(4003) May 26,2022 Rural Health Unit Cyril C. Dominguez
San Sebastian,Lagonoy, Camarines Sur 2022-2218 Jemilyn,25 y/o,G4P3(4003)PU,40 weeks 1:00 AM Panday St.,Goa,Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,8-9 cm dilated,90% Contact No.#0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
clear,station +3.
20. Maricel Boñaga Penilla G3P2(3002) May 26,2022 Rural Health Unit Cyril C. Dominguez
Tinawagan, Tigaon, Camarines Sur 2022-2219 Maricel,25y/o,G4P3(4003)PU,38weeks 2:30 PM Panday St.,Goa, Camarines Sur 09101868007 Clinical Instructor Lic.#0174893
AOG,cephalic in labor,7-8 cm dilated,80% Contact No.#0950-534-2377
effaced,BOW intact,amniotic fluid Exp.03/29/24
meconium,station +2.
Note: 1.) For graduate midwives: Supervision must be by qualified faculty/ clinical instructor.
2.) Registered Midwives/ Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries
Handled to the Board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993.
SUBSCRIBED AND SWORN, to before me this
_________________ at __________________ Affiant CERTIFIED CORRECT:
Exhibiting to me his/her Residence Certificate No.________ AFFIX
Issued at _____________ on _______________ Documentary Stamp
(to be posted on the page) Signature: ____________________ Date _____________
Printed Name: KRISTYL JOY F. BERMIDO RN,RM,MAN.
Designation:OIC/ Principal of Midwifery
License Number:RN-0443046 Expiry Date: 12/11/2024
RM-0148086 Expiry Date: 12/11/2024