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PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Deliveries Handled Please Check: Graduate Midwife
Registered Nurse
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Case No.
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
Documentary Stamp (to be posted on the last page)
Signature: ______________________ Date: ____________ Printed Name: ALICIA D. NUYDA, RM, RN, MAN o Designation: Principal/Asst. Dean/Clinical Coordinator o License Number: 0094571 Expiry Date: August 3, 2013
PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Suturing of Perineal Laceration Please Check: Graduate Midwife
Registered Nurse
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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)
PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Intravenous Insertions
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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
SUBSCRIBED
AND SWORN To before me this ____________________ at _____________________Affiant exhibiting to me his/her Residence Certificate No. _______________ issued at ________________________ on ___________________.
CERTIFIED CORRECT:
Affix
Documentary Stamp (to be posted on the last page)
Signature: ______________________ Date: ____________ Printed Name: ALICIA D. NUYDA, RM, RN, MAN o Designation: Principal/Asst. Dean/Clinical Coordinator o License Number: 0094571 Expiry Date: August 3, 2013