PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
PRC FORM No. 106
(Revised January 2011)
Record of Actual Deliveries Handled
Record of Actual Delivery Handled
Please chec(CONTINUED NEXT PAGE)___________Health
and Allied Medical Sciencesicense Number:
___________________________
Expiry Date : _____k if
Name of Applicant: ________________________________________
La Union Campus
applicant
is: Memorial State University; South
School: Don Mariano
Marcos
Graduate Midwife
Registered Nurse
Name and Address of
Patient
Case
No
Complete
Diagnosis
(Gravida, Para)
Date &
Time
Performed
Full Name, Address of
Facility & Contact
Number
Check
if
Home
Delive
ry
Supervised by
Printed Name
and Contact No.
Position /
Designatio
n
Signature
License
No /
Expiry
Date
1
2
3
4
5
6
7
8
9
10
11
(continued next page)
12
13
Name and Address of
Patient
Case
No
Complete
Diagnosis
(Gravida, Para)
Date &
Time
Performed
Full Name, Address of
Facility & Contact
Number
Check
if
Home
Delive
ry
Supervised by
Printed Name
and Contact No.
Position /
Designatio
n
Signature
License
No /
Expiry
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:
_______________________________.
Affix
Administering Officer or Notary Public
Documentary
Stamp
Signature: __________________________________________________
Date:
___________________________
Printed Name: OFELIA O. VALDEHUEZA
Designation: Director-Institute of Community Health and Allied Medical
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: ________________________________________
South La Union Campus
applicant
is: Marcos Memorial State University;
School: Don
Mariano
Graduate Midwife
Registered Nurse
Name and Address of
Patient
Case
No
Complete
Diagnosis
(Gravida, Para)
Date &
Time
Performed
Full Name, Address of
Facility & Contact
Number
Check
if
Home
Delive
ry
Supervised by
Printed Name
and Contact No.
Position /
Designatio
n
Signature
License
No /
Expiry
Date
1
2
3
4
5
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:
_______________________________.
Affix
Administering Officer or Notary Public
Documentary
Stamp
Signature: __________________________________________________
Date:
___________________________
Printed Name: OFELIA O. VALDEHUEZA
Designation: Director-Institute of Community Health and Allied Medical
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: ________________________________________
South La Union Campus
applicant
is: Marcos Memorial State University;
School: Don
Mariano
Graduate Midwife
Registered Nurse
Name and Address of
Patient
Case
No
Complete
Diagnosis
(Gravida, Para)
Date &
Time
Performed
Full Name, Address of
Facility & Contact
Number
Check
if
Home
Delive
ry
Supervised by
Printed Name
and Contact No.
Position /
Designatio
n
Signature
License
No /
Expiry
Date
1
2
3
4
5
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:
_______________________________.
Affix
Administering Officer or Notary Public
Documentary
Stamp
Signature: __________________________________________________
Date:
___________________________
Printed Name: OFELIA O. VALDEHUEZA
Designation: Director-Institute of Community Health and Allied Medical
Sciences
License Number: 0108054
Expiry Date : Renewal on process
mito 2011
