PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY

PRC FORM No. 106

Record of Actual Deliveries Handled
(Revised January 2011)

Record of Actual Delivery Handled

Please chec(CONTINUED NEXT PAGE)___________Health
and Allied Medical Sciencesicense Number:
___________________________ Expiry Date : _____k if
Name of Applicant: ________________________________________ applicant
School: Don Mariano is: Memorial State University; South
Marcos
La Union Campus Graduate Midwife Registered Nurse
 Check
Supervised by
Complete Date & Full Name, Address of if License
Name and Address of Case Position /
Diagnosis Time Facility & Contact Home Printed Name No /
Patient No (Gravida, Para) Performed Number Delive Designatio Signature
ry and Contact No. Expiry
n
Date
1

10

11
(continued next page)
12

13
 Check
Supervised by
Complete Date & Full Name, Address of if License
Name and Address of Case Position /
Diagnosis Time Facility & Contact Home Printed Name No /
Patient No (Gravida, Para) Performed Number Delive Designatio Signature
ry and Contact No. Expiry
n
Date
14

15

16

17

18

19

20

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:

Signature: __________________________________________________ Date:

___________________________
Affix Printed Name: OFELIA O. VALDEHUEZA
Administering Officer or Notary Public Documentary Designation: Director-Institute of Community Health and Allied Medical
Stamp Sciences
License Number: 0108054 Expiry Date : Renewal on process
mito 2011
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY

PRC FORM No. 107

(Revised January 2011)
Record of Actual Deliveries Handled
Record of Actual Suturing of Lacerations Handled
Please chec(CONTINUED NEXT PAGE)___________Health
and Allied Medical Sciencesicense Number:
___________________________ Expiry Date : _____k if
Name of Applicant: ________________________________________ applicant
School: Don Mariano is: Marcos Memorial State University;
South La Union Campus Graduate Midwife Registered Nurse
 Check
Supervised by
Complete Date & Full Name, Address of if License
Name and Address of Case Position /
Diagnosis Time Facility & Contact Home Printed Name No /
Patient No (Gravida, Para) Performed Number Delive Designatio Signature
ry and Contact No. Expiry
n
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:

Signature: __________________________________________________ Date:

___________________________
Affix Printed Name: OFELIA O. VALDEHUEZA
Documentary Designation: Director-Institute of Community Health and Allied Medical
Administering Officer or Notary Public
Stamp Sciences
License Number: 0108054 Expiry Date : Renewal on process
mito 2011
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY

PRC FORM No. 107-A

(Revised January 2011)
Record of Actual Deliveries Handled
Record of Actual Intravenous Insertions
Please chec(CONTINUED NEXT PAGE)___________Health
and Allied Medical Sciencesicense Number:
___________________________ Expiry Date : _____k if
Name of Applicant: ________________________________________ applicant
School: Don Mariano is: Marcos Memorial State University;
South La Union Campus Graduate Midwife Registered Nurse
 Check
Supervised by
Complete Date & Full Name, Address of if License
Name and Address of Case Position /
Diagnosis Time Facility & Contact Home Printed Name No /
Patient No (Gravida, Para) Performed Number Delive Designatio Signature
ry and Contact No. Expiry
n
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:

Signature: __________________________________________________ Date:

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