Académique Documents
Professionnel Documents
Culture Documents
Manila
BOARD OF MIDWIFERY
(continued next page)
Record of Actual Delivery Handled
Name of Applicant: ESTRELLA, SAM ANGELO F.
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
Signature
License No /
Expiry Date
1
2
3
4
5
6
7
8
9
10
Please check if applicant is:
Graduate Midwife Registered Nurse
PRC FORM No. 106
(Revised January 2011)
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
Signature
License No /
Expiry 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 _______________________________.
Administering Officer or Notary Public
Affix
Documentary Stamp
to be posted on the last page
CERTIFIED CORRECT:
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
Record of Actual Suturing of Lacerations Handled
Name of Applicant: ESTRELLA, SAM ANGELO F.
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
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 _______________________________.
Administering Officer or Notary Public
PRC FORM No. 107
(Revised January 2011)
Please check if applicant is:
Graduate Midwife Registered Nurse
Affix
Documentary Stamp
to be posted on the last page
CERTIFIED CORRECT:
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
Record of Actual Intravenous Insertions
Name of Applicant: ESTRELLA, SAM ANGELO F.
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
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 _______________________________.
Administering Officer or Notary Public
PRC FORM No. 107-A
(Revised January 2011)
Please check if applicant is:
Graduate Midwife Registered Nurse
Affix
Documentary Stamp
to be posted on the last page
CERTIFIED CORRECT:
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