PROFESSIONAL REGULATION COMMISION

Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Please Check:
Graduate Midwife

PRC FORM No. 106

(Revised October
2010)

Name of Applicant: Josephine M. Rivera

Name and Address of
Patient

1. RIA MAE ROTAQUIO

LEONES, BRGY.
NONONG, SAN LUIS,
AURORA
2.
3.
4.
5.
6.
7.
8.
9.
10.

Case
No.

141114

Complete Diagnosis
(Gravida_Para_)

Registered Nurse

School: University of the Philippines- Manila, School of Health Sciences

Date &
Time
Performed

Full Name,
Address of Facility
& Contact Number

Check
if
Home
Del.

Supervised by:
Printed Name &
Contact No.

Position/
Designation

Signature

License No./
Expiration
Date

(Continued at the Back)

Name and Address of

Patient

Case
No.

Complete Diagnosis
(Gravida_Para_)

Date &
Time
Performed

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.

AND SWORN To before me this
____________________
at
_____________________Affiant
exhibiting to me his/her Residence Certificate No. _______________
issued at ________________________ on ___________________.

CERTIFIED CORRECT:

SUBSCRIBED

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

Affix

Documentary Stamp
(to be posted on the last
page)

PROFESSIONAL REGULATION COMMISION

Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Laceration
Please Check:
Graduate Midwife

PRC FORM No. 107

(Revised October
2010)

Name of Applicant: _______________________________________________

Name and Address of
Patient

1.

2.

3.

4.

5.

Case
No.

Complete Diagnosis
(Gravida_Para_)

Date &
Time
Performed

Registered Nurse

School: CAMARINES SUR POLYTECHNIC COLLEGES

Full Name,
Address of Facility
& Contact Number

Check
if
Home
Del.

Supervised by:
Printed Name &
Contact No.

Position/
Designation

Signature

License No./
Expiration
Date

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

PRC FORM No. 107-A

(Revised October
2010)

Name of Applicant: _______________________________________________

Name and Address of
Patient

Case
No.

Complete Diagnosis
(Gravida_Para_)

Date &
Time
Performed

School: CAMARINES SUR POLYTECHNIC COLLEGES

Full Name,
Address of Facility
& Contact Number

Check
if
Home
Del.

1.

2.

3.

4.

5.

Note: 1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.

Supervised by:
Printed Name &
Contact No.

Position/
Designation

Signature

License No./
Expiration
Date

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