PROFESSIONAL REGULATION COMMISSION
Baguio
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Please Check:
` Graduate Midwife Registered Nurse
Name of Applicant: __________________________ School: QUIRINO STATE UNIVERSITY
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility Supervised by:
Diagnosi Performed & Contact Number
s Printed Name & Position/ Signature License
(Gravida Contact Number Designation No./Exp.
_Para) Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Page 1 of 10
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility Supervised by:
Diagnosi Performed & Contact Number
s Printed Name & Position/ Signature License
(Gravida Contact Number Designation No./Exp.
_Para) Date
11.
12.
13.
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: _______________________________________________
Designation: ________________________________________________
Documentary Stamp (to be posted on Lic. No.: ___________________ Expiry Date: _____________________
The last page of every case)
___________________________________
Administering Officer or Notary Public
Page 2 of 10
PROFESSIONAL REGULATION COMMISSION
Baguio
BOARD OF MIDWIFERY
Record of Assist Handled
Please Check:
Graduate Midwife Registered Nurse
Name of Applicant: _________________________________________ School: QUIRINO STATE UNIVERSITY
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility Supervised by:
Diagnosi Performed & Contact Number
s Printed Name & Position/ Signature License
(Gravida Contact Number Designation No./Exp.
_Para) Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Page 3 of 10
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility Supervised by:
Diagnosi Performed & Contact Number
s Printed Name & Position/ Signature License
(Gravida Contact Number Designation No./Exp.
_Para) Date
11.
12.
13.
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: _______________________________________________
Designation: ________________________________________________
Documentary Stamp (to be posted on Lic. No.: ___________________ Expiry Date: _____________________
The last page of every case)
___________________________________
Administering Officer or Notary Public
Page 4 of 10
PROFESSIONAL REGULATION COMMISSION
Baguio
BOARD OF MIDWIFERY
Record of Cord Care Handled
Please Check:
Graduate Midwife Registered Nurse
Name of Applicant:_______________________________________ School: QUIRINO STATE UNIVERSITY
Name of Patient& Case no. Complete Anthropometric Measurements Date and time Full Name, Address of Facility Supervised by:
Gender Of the Diagnosi Performed & Contact Number
HC CC AC BL BW Printed Name Position/ Signature License
s
Baby (CM) (CM) (CM) (CM) (Grams) &Contact No. Designation No./Exp.
Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Name of Patient& Case no. Complete Anthropometric Measurements Date and time Full Name, Address of Facility Supervised by:
Page 5 of 10
Gender Of the Diagnosi HC CC AC BL BW Performed & Contact Number Printed Name Position/ Signature License
Baby s (CM) (CM) (CM) (CM) (Grams) &Contact No. Designation No./Exp.
Date
11.
12.
13.
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: _______________________________________________
Designation: ________________________________________________
Documentary Stamp (to be posted on Lic. No.: ___________________ Expiry Date: _____________________
The last page of every case)
___________________________________
Administering Officer or Notary Public
PROFESSIONAL REGULATION COMMISSION
Page 6 of 10
Baguio
BOARD OF MIDWIFERY
Record of Intravenous Insertion Handled
Please Check:
Graduate Midwife Registered Nurse
Name of Applicant: ____________________________________ School: QUIRINO STATE UNIVERSITY
Complete Date and Time Full Name, Address of Supervised by:
Name and Address of Patient Case No. Diagnosis Performed Facility & Contact Number
Printed Name Position/Designation License
(Gravida_
& Contact Signature No./Exp.
Para)
No. Date
1.
2.
3.
4.
5.
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: _______________________________________________
Designation: ________________________________________________
Documentary Stamp (to be posted on Lic. No.: ___________________ Expiry Date: _____________________
The last page of every case)
___________________________________
Administering Officer or Notary Public
Page 7 of 10
PROFESSIONAL REGULATION COMMISSION
Baguio
BOARD OF MIDWIFERY
Record of Suture Handled
Please Check:
Graduate Midwife Registered Nurse
Name of Applicant: __________________________________ School: QUIRINO STATE UNIVERSITY
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility & Supervised by:
Diagnosis Performed Contact Number
Printed Name Position/Designation Signature License
(Gravida_
& Contact No./Exp.
Para)
No. Date
1.
2.
3.
4.
5.
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: _______________________________________________
Designation: ________________________________________________
Documentary Stamp (to be posted on Lic. No.: ___________________ Expiry Date: _____________________
The last page of every case)
___________________________________
Administering Officer or Notary Public
Page 8 of 10
PROFESSIONAL REGULATION COMMISSION
Baguio
BOARD OF MIDWIFERY
Record of Internal Examination Handled
Please Check:
` Graduate Midwife Registered Nurse
Name of Applicant: __________________________ School: QUIRINO STATE UNIVERSITY
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility & Supervised by:
Diagnosis Performed Contact Number
(Gravida Printed Name & Contact Position/ Signature License
_Para) Number Designation No./Exp.
Date
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Page 9 of 10
Name and Address of Patient Case No. Complete Date and Time Full Name, Address of Facility & Supervised by:
Diagnosis Performed Contact Number
(Gravida Printed Name & Contact Position/ Signature License
_Para) Number Designation No./Exp.
Date
11.
12.
13.
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: _______________________________________________
Designation: ________________________________________________
Lic. No.: ___________________ Expiry Date: _____________________
Documentary Stamp (to be posted on
The last page of every case)
___________________________________
Administering Officer or Notary Public
Page 10 of 10
