Name and Address of Patient Case Complete Diagnosis Date and Full Name, Address Check

Supervised By:
No. (Gravida, Para_) Time of Facility & if
Performe Contact Number Home Printed Name & Position/ License No./
Contact No. Designation Signature Exp. Date
d Del.
e.g. Teresa, 25 years old, G2P2
(2002)
PU 39 weeks & 5 days, cephalic, in
labor, delivered NSD to a live baby
boy, APGAR=9,BW=2950 grams

PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION

(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handle (20 deliveries)
Please Check:
∕ Graduate Midwife Registered nurse

Name of Applicant: STO. DOMINGO, JOVELLE BORREGA. School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
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:_________________________________________
Designation: _____________________________
License Number: Expiry Date:
Expiry Date:
PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION
(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Laceration (5 suturing)

Please Check:
∕ Graduate Midwife Registered nurse
Name of Applicant: STO. DOMINGO, JOVELLE BORREGA School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
Name and Address of Case Complete Diagnosis Date and Full Name, Address Check if
Patient No. ( Gravida_Para_) Time of Facility & Contact Home Supervised By:
Performed Number Del. Printed Name & Position/ License No./
Contact No. Designation Signature Exp. Date
e.g., Adela, 25 years old, G2P2 PU 39
weeks, cephalic in labor, delivered
NSD to a live baby boy APGAR=9
BW=3100 grams. (Add degree of
laceration), 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.

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:_________________________________
Designation: _____________________________
License Number: Expiry Date:
Expiry Date:
PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION
(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions (5 IV)
Please Check:

√ Graduate midwife Registered nurse

Name of Applicant: STO. DOMINGO, JOVELLE BORREGA School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
Name and Address of Patient Case Complete Diagnosis Date and Full Name, Address of Check if
No. ( Gravida_Para_) Time Facility & Contact Home Supervised By:
Performed Number Del. Printed Name & Position/ License
Contact No. Designation Signature No./ Exp.
Date
e.g. Cora, 28 years old G3P2
(2002), PU 40 weeks, cephalic
in labor.
If delivered/postpartum:
e.g. Rosa, 32 years old G5P3
(3113), PU 40 weeks, cephalic,
NSD to a live baby girl
BW=3200 grams Post Partum
Hemorrhage

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

Signature: ____________________ Date _____________

Printed Name:___________________________________
Designation: _____________________________
License Number: Expiry Date:
Expiry Date:
 PRC FORM No. 106 PROFESSIONAL REGULATION COMMISSION
(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Internal Examination (20 IE)
Please Check:
√ Graduate Midwife Registered nurse

Name of Applicant: STO. DOMINGO, JOVELLE BORREGA School: FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY, INC.
Name and Address of Patient Case Complete Diagnosis Date and Full Name, Address of Check
Supervised By:
No. ( Gravida_Para_) Time Facility & Contact if
Performed Number Home Printed Name & Position/ License No./
Del. Contact No. Designation Signature Exp. Date
e.g. Clara, 27 years old G2P1
(1001) PU 39 weeks AOG,
cephalic in labor, 5-6 cm dilated,
50% effaced, BOW ( intact or
ruptured), amniotic fluid (clear,
meconium,bloody), station ( 0,+,-)
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:___________________________________
Designation: _____________________________
License Number:____________ Expiry Date: _________
____________ Expiry Date:_________