PRC FORM No.

106 PROFESSIONAL REGULATION COMMISSION

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

 Graduate Midwife Registered Nurse

Name of Applicant: Keana Concepcion J. Depita School: Notre Dame Hospital and Siena College of Cotabato, Inc.
Name and Address of Patient CASE Complete Diagnosis Date & Full Name, Address of Facility & Check Supervised By:
NO. (Gravida__Para___) Time Contact Number if Printed Name & Contact No. Position/ Signature License
Performed Home Designation No./
Del. Exp. Date
1. Bernadette D. Dioquino, 25y/o 21-267 Gravida 1 Para 1 (1001) pregnancy uterine full term 39 weeks of 10-07-21 Poblacion MB Health & Birthing Clinic Waynie P. Usman, RM Clinical 0057231
RH 2, Cotabato City gestation, cephalic presentation, delivered spontaneously to a live term 10:40pm Pob. Mother, Cotabato City 09772113747 Instructor 06-18-24
baby girl, BW-3.0kg., AS-8,9, BL-49cm. #09267712674

(Continued at the back

Name and Address of Patient CASE Complete Diagnosis Date & Full Name, Address of Facility & Check Supervised By:
NO. (Gravida__Para___) Time Contact Number if Printed Name & Contact No. Position/ Signature License
 Performed Home Designation No./
Del. Exp. Date

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 CERTIFICATION NO. ________________________
issued at _____________________________________ on _____________________________.
CERTIFIED CORRECT:
________________________________ AFFIX Signature: _______________________________________________Date: _________________
Administering Officer or Notary Public Name in Print: __ IVY C. PEÑAFIEL-ABUDA, RM, MAHPED__ _
DOCUMENTARY STAMP
Designation: _ _ DEAN_______ _
Page No.:_________________ (to be posted on the last page) License No.: 0158161 __Expiry Date: _January 15, 2025
Doc. No.:_________________
Book No:_________________
Series of _________________

PRC FORM No.106 PROFESSIONAL REGULATION COMMISSION

(Revised January 2011) Manila
 BOARD OF MIDWIFERY
Record of Internal Examination
Please Check if applicant is:

 Graduate Midwife Registered Nurse

Name of Applicant:____________________________ School: Notre Dame Hospital and Siena College of Cotabato, Inc.
Name and Address of Patient CASE Internal Examination Date & Full Name, Address of Facility & Check Supervised By:
Time if Home
NO. (Cervical Dilation, Effacement, BOW, Presentation, Station) Contact Number Del. Printed Name & Contact No. Position/ Signature License
Performed Designation No./
Exp. Date
1. Bernadette D. Dioquino, 25y/o 21-267 Gravida 2 Para 1 (1001) pregnancy uterine 39 weeks of gestation, 10-07-21 Poblacion MB Health & Birthing Clinic Waynie P. Usman, RM Clinical 0057231
RH 2, Cotabato City cephalic in labor, 10cm dilated, 95% effaced, Bag of water intact, 10:40pm Pob. Mother, Cotabato City 09772113747 Instructor 06-18-24
amniotic fluid clear station +3. #09267712674

(Continued at the back)

Name and Address of Patient CASE Internal Examination Date & Full Name, Address of Facility & Check Supervised By:
NO. (Cervical Dilation, Effacement, BOW, Presentation, Station) Time Contact Number if Printed Name & Contact No. Position/ Signature License
Performed Home Designation No./
 Del. Exp. Date

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 CERTIFICATION NO. ________________________
issued at _____________________________________ on _____________________________.
CERTIFIED CORRECT:
________________________________ Signature: _______________________________________________Date: _________________
AFFIX
Administering Officer or Notary Public Name in Print: __ IVY C. PEÑAFIEL-ABUDA, RM, MAHPED__ _
DOCUMENTARY STAMP
Designation: _ _ DEAN_______ _
Page No.:_________________ (to be posted on the last page) License No.: 0158161 __Expiry Date: _January 15, 2025
Doc. No.:_________________
Book No:_________________
Series of _________________

PRC FORM No.107 PROFESSIONAL REGULATION COMMISSION

(Revised January 2011) Manila
 BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Lacerations
Please Check if applicant is:

 Graduate Midwife Registered Nurse

Name of Applicant: ____________________________ School: Notre Dame Hospital and Siena College of Cotabato, Inc.
Name and Address of Patient CASE Complete Diagnosis Date & Time Full Name, Address of Facility & Check Supervised By:
NO. (Gravida__Para___) Performed Contact Number if Printed Name & Contact Position/ Signature License No./
Home Designation Exp. Date
Del.
No.

1. Bernadette D. Dioquino, 25y/o 21-267 Gravida 1 Para 1 (1001) pregnancy uterine full term 39 weeks of 10-07-21 Poblacion MB Health & Birthing Clinic Waynie P. Usman, RM Clinical 0057231
RH 2, Cotabato City gestation, cephalic presentation, delivered spontaneously to a live 10:57pm Pob. Mother, Cotabato City 09772113747 Instructor 06-18-24
term baby girl, BW-3.0kg., AS-8,9, BL-49cm. Sutured 2nd degree of #09267712674
laceration.

NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.
2.) 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, Series of 1993, dated December 1, 1993.

(See back page)

PRC FORM No.107-A PROFESSIONAL REGULATION COMMISSION

(Revised January 2011) Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions
Name of Applicant: ____________________________ School: Notre Dame Hospital and Siena College of Cotabato, Inc.
Name and Address of Patient CASE Complete Diagnosis Date & Time Full Name, Address of Facility & Check Supervised By:
NO. (Gravida__Para___) Performed Contact Number if Printed Name & Contact No. Position/ Signature License
Home Designation No./
Del. Exp.
Date
1. Kalima S. Ala, 32y/o 21-858 Gravida 4 Para 4 (4004) pregnancy uterine full term 41 weeks of 12-06-21 Bagua Lying-in Clinic Waynie P. Usman, RM Clinical 0057231
Bagua II, Cotabato City gestation, cephalic presentation, delivered spontaneously to a live term 10:45pm Soledad Extn., Bagua II, Cotabato City 09772113747 Instructor 06-18-24
baby boy, BW-3.3kg., AS-8,9, BL-50cm. IVF inserted due to pale #5574422
appearance.

NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.
2.) 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, Series of 1993, dated December 1, 1993.

SUBSCRIBED AND SWORN TO before me this ________________________ at ___________________________ affiant exhibiting to me his/her RESIDENCE CERTIFICATION NO. _______________________
issued at _____________________________________ on _____________________________.
CERTIFIED CORRECT:
________________________________ Signature: ___________________________________________ Date: ______________
AFFIX
Administering Officer or Notary Public Name in Print: IVY C. PEÑAFIEL-ABUDA, RM, MAHPED___
DOCUMENTARY STAMP
Designation: _ _ DEAN _
Page No.:_________________ (to be posted on the last page) License No.: 0158161__Expiry Date: _January 15, 2025
Doc. No.:_________________
Book No:_________________
Series of _________________
 Notre Dame Hospital and Siena College of Cotabato, Inc.
Rosary Heights, Cotabato City
Tel.Fax # (064) 421-51-33
Record of Actual Observed Deliveries

Name of Applicant: ____________________________ School: Notre Dame Hospital and Siena College of Cotabato, Inc.
NO. CASE NO. NAME OF PATIENT DATE and Diagnosis Name, Address of facility & Contact # SUPERVISED BY: DESIGNATION PRC
ADDRESS TIME Gravida___ Para ____, type of delivery, gender of the LICENSE
DELIVERED baby, BW____ BL ____ NO.
1. 19-088 Samraida M. Sumlay 09-27-19 Gravida 4 Para 4 (4004) pregnancy uterine full term 40 Poblacion MB Health & Birthing Clinic Waynie P. Usman, RM Clinical 0057231
Lumayon I, POB MB, Cotabato City 09:19pm weeks of gestation cephalic presentation delivered Pob. Mother, Cotabato City 09772113747 Instructor 06-18-24
spontaneously to a live term baby boy, BW-3.0 kg., AS-8,9 #09267712674
BL-50cm.
2.

3.

4.

5.

6.

7.

8.

9.

10.

Cont. of observed at the back

NO. CASE NO. NAME OF PATIENT DATE and Diagnosis Name, Address of facility & Contact # SUPERVISED BY: DESIGNATION PRC
ADDRESS TIME Gravida___ Para ____, type of delivery, gender of the baby, LICENSE
DELIVERED BW____ BL ____ NO.
 11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

CERTIFIED CORRECT:

Signature: _________________________________________ Date: ________________

Name in Print: IVY C. PEÑAFIEL-ABUDA, RM, MAHPED_
Designation: ______ __DEAN____________________

Notre Dame Hospital and Siena College of Cotabato, Inc.

Rosary Heights, Cotabato City
Tel.Fax # (064) 421-51-33
Record of Actual Assisted Deliveries

Name of Applicant: ____________________________ School: Notre Dame Hospital and Siena College of Cotabato, Inc.
NO. CASE NO. NAME OF PATIENT DATE and Diagnosis Name, Address of facility & Contact # SUPERVISED BY: DESIGNATION PRC
ADDRESS TIME Gravida_ Para _, type of delivery, gender of the baby, BW_ BL _ LICENSE NO.
DELIVERED
1. 20-15 Rahma K. Gayao 07-20-20 Gravida 4 Para 4 (4004) pregnancy uterine full term 40 weeks of Mo. Francisca Birthing Home Clinic Inc. Ivy C. Peñafiel-Abuda, RM Clinical 0158161
RH10, Cotabato City 07:08am gestation cephalic presentation delivered spontaneously to a live term NDH Compound, RH9, Cotabato City 09124746509 Instructor 01-15-25
baby girl, BW- 3.2kg., AS-7,9, BL-50cm. #(064)421-5133
2.

3.
4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Cont. of assistat the back

NO. CASE NO. NAME OF PATIENT DATE and TIME Diagnosis Name, Address of facility & Contact # SUPERVISED BY: DESIGNATION PRC
ADDRESS DELIVERED Gravida_ Para _, type of delivery, gender of the baby, BW_ BL _ LICENSE NO.
16.

17.

18.

19.

20.

21.

22.
 23.

24.

25.

26.

27.

28.

29.

30.

CERTIFIED CORRECT:
Signature: ____________________________________________Date: ______________
Name in Print: __IVY C. PEÑAFIEL-ABUDA, RM, MAHPED__
Designation: ______ ___DEAN_______________________

Notre Dame Hospital and Siena College of Cotabato, Inc.

Rosary Heights, Cotabato City
Tel.Fax # (064) 421-51-33
Record of Actual Newborn Care

Name of Applicant: ____________________________ School: Notre Dame Hospital and Siena College of Cotabato, Inc.
NO. CASE DATE and Complete Diagnosis NAME OF MOTHER Name, Address of facility & SUPERVISED BY: DESIGNATION PRC
NO. TIME OF Gravida __ ,Para__ , Anthropometric data: Address Contact # LICENSE
BIRTH (HC _ , CC _ , AC _ , BL _) NO.
1. 21-137 09-21-21 Gravida 4 Para 4 (4004) pregnancy uterine delivered Haffa A. Ali Doc. RBM Lying-in and OB Gyne Clinic Waynie P. Usman, RM Clinical 0057231
02:38pm spontaneously to a live term baby boy, BW-2.9kg., AS-7,9, Buldon, Maguindanao Poblacion 1, Parang, Maguindanao 09772113747 Instructor 06-18-24
HC- 33 CC- 32, AC-29, BL-49cm. #09554501063
2.

3.

4.
5.

6.

7.

8.

9.

10.

Cont. of Actual Newborn Care at the back

NO. CASE DATE and Complete Diagnosis NAME OF MOTHER Name, Address of facility & SUPERVISED BY: DESIGNATION PRC
NO. TIME OF Gravida __ ,Para__ , Anthropometric data: Address Contact # LICENSE
BIRTH (HC _ , CC _ , AC _ , BL _) NO.
11.

12.

13.

14.

15.

CERTIFIED CORRECT:

Signature: _____________________________________________Date:_____________
Name in Print: _IVY C. PEÑAFIEL-ABUDA, RM, MAHPED____
Designation: ______ DEAN____________