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PRC FORM No.

106
(Revised October 2010)

PROFESSIONAL REGULATION COMMISSION


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

Name of Applicant:

JONETH D. DE VERA

Name and Address of Patient

Case No.

1. Rosalinda Primavera Respeto

4639

2. Maricel Bono Nazareno

4694

3. Nel Dela Torre Dario

4718

4. Editha Raola Pitallano

4768

5. VIlma Dadis Sanje

4786

6. Sylvia Carbonell Gelian

4924

7. Fe Asetre Aluzay

4930

8. Hilda Flores Araes

4887

9. Cyril Paat

4889

10. Corne Mass Arneta

4893

Compete Diagnosis
(Gravida_Para_)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G5P5 (5005)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G3P3 (3003)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G3P3 (3003)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G8P8 (8008)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G3P3 (3003)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

School:

Date and Time


Performed

Registered Nurse

FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY INC.

Check
Full Name, Address of
if
Facility & Contact
Home Printed Name &
Number
Del.
Contact No.

Supervised By:
Position/
Designation

Signature

License No. /
Exp. Date

09-24-05
8:10am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

09-25-05
4:45am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

09-28-05
6:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-04-05
4:50am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-08-05
6:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-27-05
7:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-27-05
12:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-22-05
1:45am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-22-05
11:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-23-05
6:30am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

(Continue at the Back)

Name and Address of Patient

Case No.

11. Vilma Dela Cruz

4910

12. Device Rosero

4948

13. Salve Coa

4965

14. Eva Verdezo

4975

15. Naome Cadag

5002

16. Elvie Redondo

5003

17. Marina Beuna

5017

18. Marie Ann Rivero

5094

19. Cherryle Obias

5077

20. Lanie Araes Tibi

5086

Note:

Compete Diagnosis
(Gravida_Para_)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G9P9 (9009)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G4P4 (4004)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G4P4 (4004)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G6P6 (6006)

Date and Time


Performed

Check
Full Name, Address of
if
Facility & Contact
Home Printed Name &
Number
Del.
Contact No.

Supervised By:
Position/
Designation

Signature

License No. /
Exp. Date

10-25-05
9:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-01-05
2:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-09-05
6:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-05-05
3:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-09-05
8:35pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-10-05
9:45pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-11-05
11:35pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-14-05
8:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-20-05
10:10am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-22-05
12:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

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


2.) Registered Midwives/Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries Handled to the
Board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993.

CERTIFIED CORRECT:

____ at ____________________ Affiant exhibiting to me his/her Residence Certificate No. ____________ Issued at ________________

A F F I X
Documentary Stamp
(to be posted on the page)

on _________________.
Signature: Date:
Printed Name: EVANGELINE F. DOTILLOS RM, RN, MAN
Designation:
OIC/Principal of Midwifery
License Number: RN 0657024
Expiry Date: 9/23/16
RM 0147922
Expiry Date: 9/23/16

PRC FORM No. 106


(Revised October 2010)

PROFESSIONAL REGULATION COMMISSION


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

Name of Applicant:

JONETH D. DE VERA

Name and Address of Patient

1. Madelyn P. Dantes
San Antonio, San Jose
2. Cynthia N. Rizola
Omato, Lagonoy
3. Merly C. MIzamis
Tabgon, Goa
4. Laylin S. Milante
Loho, Lagonoy
5. Gina Capuz Sabado
San Jose
Note:

Case No.

Compete Diagnosis
(Gravida_Para_)

School:

Date and Time


Performed

Registered Nurse

FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY INC.

Check
Full Name, Address of
if
Facility & Contact
Home
Number
Del. Printed Name &
Contact No.

Supervised By:
Position/
Designation

Signature

License No. /
Exp. Date

5157

Pregnancy Uterine Delivered


NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

12-04-05
12:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Jovenal L. Peaflorida,
MD

Clinical
Instructor

MD: 0042804
Exp: Nov. 27, 2016

5160

Pregnancy Uterine Delivered


NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

12-16-05
10:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Jovenal L. Peaflorida,
MD

Clinical
Instructor

MD: 0042804
Exp: Nov. 27, 2016

5143

Pregnancy Uterine Delivered


NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

12-20-05
1:30pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Jovenal L. Peaflorida,
MD

Clinical
Instructor

MD: 0042804
Exp: Nov. 27, 2016

5058

Pregnancy Uterine Delivered


NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

12-03-05
1:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Jovenal L. Peaflorida,
MD

Clinical
Instructor

MD: 0042804
Exp: Nov. 27, 2016

5026

Pregnancy Uterine Delivered


NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

12-19-05
11:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Jovenal L. Peaflorida,
MD

Clinical
Instructor

MD: 0042804
Exp: Nov. 27, 2016

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


2.) Registered Midwives/Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries Handled to the
board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993.

PRC FORM No. 106


(Revised October 2010)

PROFESSIONAL REGULATION COMMISSION


Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions
Please Check:
Graduate Midwife

Name of Applicant:

JONETH D. DE VERA

Name and Address of Patient

Case No.

1. Herson I. Plaero
Lamon Goa, Camarines Sur

5131

2. Arnel R. Primo
San Isidro

5132

3. Andro P. Rodriguez
Bag. Grande

5136

4. Tames D. Rimando
San Isidro

5120

5. Nena B. Pacis
Balaynan

5069

Note:

Compete Diagnosis
(Gravida_Para_)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G2P2 (2002)
Pregnancy Uterine Delivered
NSD with RMLE full term,
Cephalic,Episiorrhaphy Done
G1P1 (1001)

School:

Date and Time


Performed

Registered Nurse

FATIMA SCHOOL OF SCIENCE AND TECHNOLOGY INC.

Check
Full Name, Address of
if
Facility & Contact
Home Printed Name &
Number
Del.
Contact No.

Supervised By:
Position/
Designation

Signature

License No. /
Exp. Date

10-02-05
7:10pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

10-08-05
7:20pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-21-05
7:00pm

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

11-21-05
12:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

12-07-05
9:00am

Goa Municipal Infirmary


Burgos, St. Goa, Cam. Sur
Tel No. (054) 453-1486

Severa R. Lanuzo, RM
09982507875

Clinical
Instructor

RM: 00117577
Exp: May 5, 2016

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


2.) Registered Midwives/Clinical Instructors who supervise student midwives and affects their signature in this Form must present Certificate of Training on Actual Deliveries Handled to the
Board pursuant to Board Resolution number 100, Series of 1993, dated December 1, 1993.

CERTIFIED CORRECT:

____ at ____________________ Affiant exhibiting to me his/her Residence Certificate No. ____________ Issued at ________________

A F F I X
Documentary Stamp
(to be posted on the page)

on _________________.
Signature: Date:
Printed Name: EVANGELINE F. DOTILLOS RM, RN, MAN
Designation:
OIC/Principal of Midwifery
License Number: RN 0657024
Expiry Date: 9/23/16
RM 0147922
Expiry Date: 9/23/16