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