PRC FORM No.
106
(Revised January 2011)
PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Name of Applicant: _________________________
School:
____________________________
Name and
Address of
Patient
1
2
3
4
5
6
7
8
9
Supervised by
Case No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Check if
Home
Facility & Contact
Printed Name
Position /
Delivery
Number
and Contact No. Designation
Signature
License No
/ Expiry
Date
10
11
12
13
14
15
16
17
18
19
20
Note:
(1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor
CERTIFIED CORRECT:
Signature: __________________________________________________
Printed Name: ______________________________________________
Designation: ________________________________________________
License Number: ____________________________________________
Date: _______________________
Expiry Date: __________________
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to
me his/her Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.
Affix Documentary Stamp
Administering Officer or
Notary Public
PRC FORM No.107
(Revised January 2011)
PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Lacerations
Name of Applicant: ______________________________
__________________________________
School:
Supervised by
Name and Address
of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Check if
Home
Facility & Contact
Printed Name
Position /
Delivery
Number
and Contact No. Designation
Signature
License No
/ Expiry
Date
1
2
3
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.
CERTIFIED CORRECT:
Signature: __________________________________________________
Printed Name: ______________________________________________
Designation: ________________________________________________
License Number: ____________________________________________
Date: ___________________________
Expiry Date: _____________________
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to
me his/her Residence Certificate No. __________________________ issued at ______________________________ on _________ _____________________.
Affix Documentary Stamp
Administering
Officer or Notary Public
PRC FORM No.107-A
(Revised January 2011)
PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions
Name of Applicant: ______________________________
__________________________________
School:
Supervised by
Name and Address
of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Check if
Home
Facility & Contact
Printed Name
Position /
Delivery
Number
and Contact No. Designation
Signature
License No
/ Expiry
Date
1
2
3
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.
CERTIFIED CORRECT:
Signature: __________________________________________________
Printed Name: ______________________________________________
Designation: ________________________________________________
License Number: ____________________________________________
Date: ___________________________
Expiry Date: _____________________
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to
me his/her Residence Certificate No. __________________________ issued at ______________________________ on _________ _____________________.
Affix Documentary Stamp
Administering Officer or Notary Public
