PRC FORM No.

106 (Revised January 2011)

PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Deliveries Handled Please Check if applicant is: Graduate Midwife Registered Nurse

Name of Applicant: _______________________________________________

Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performed

School: ___________________________________________________
Check if Home Del. Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration Date

Full Name, Address of Facility & Contact Number

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

(Continued at the Back)

Name and Address of Patient

Case No.

Complete Diagnosis (Gravida_Para_)

Date & Time Performe d

Full Name, Address of Facility & Contact Number

Check if Home Del.

Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration 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:

Affix
______________________________________________ Administering Officer or Notary Public
Documentary Stamp (to be posted on the last page)

Signature: ______________________ Date: ____________ Printed Name: ____________________________________ Designation: _____________________________________o License Number: ____________ Expiry Date: ____________

PRC FORM No. 107 (Revised January 2011)

PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Suturing of Perineal Laceration Please Check if applicant is: Graduate Midwife Registered Nurse

Name of Applicant: _____________________________________________

Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performed

School: __________________________________________________
Check if Home Del. Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration Date

Full Name, Address of Facility & Contact Number

1.

2.

3.

4.

5.

Note: 1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor. 2) Registered Midwives/Clinical Instructors who supervise student midwives and affix their signature in this Form must present Certificate of Training on Suturing of Perineal lacerations to the Board pursuant to Board Resolutions No. 100, Series of 1993, dated December 1,1993
(See back page)

PRC FORM No. 107-A (Revised January 2011)

PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Intravenous Insertions School: ________________________________________________
Check if Home Del. Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration Date

Name of Applicant: ____________________________________________

Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performe d Full Name, Address of Facility & Contact Number

1.

2.

3.

4.

5.

Note: 1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor. 2) Registered Midwives/Clinical Instructors who supervise student midwives and affix their signature in this Form must present a Certificate of Training on Intravenous Insertions to the Board pursuant to Board Resolutions No. 100, Series of 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 (to be posted on the last page)

Signature: ______________________ Date: ____________ Printed Name: ______________________________________o Designation: _______________________________________ o License Number: _________ Expiry Date: ___________