PRC FORM No.

106
(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Name of Applicant: _________________________

School:

____________________________
Name and
Address of
Patient

1
2
3
4
5
6
7
8
9

Supervised by

Case No

Complete Diagnosis
(Gravida, Para)

Date & Time

Performed

Full Name, Address of Check if

Home
Facility & Contact
Printed Name
Position /
Delivery
Number
and Contact No. Designation

Signature

License No
/ Expiry
Date

10
11
12
13
14
15
16
17
18
19
20
Note:

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

CERTIFIED CORRECT:
Signature: __________________________________________________
Printed Name: ______________________________________________
Designation: ________________________________________________
License Number: ____________________________________________

Date: _______________________

Expiry Date: __________________

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to

me his/her Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.
Affix Documentary Stamp

Administering Officer or
Notary Public
PRC FORM No.107
(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Lacerations
Name of Applicant: ______________________________
__________________________________

School:

Supervised by

Name and Address

of Patient

Case
No

Complete Diagnosis
(Gravida, Para)

Date & Time

Performed

Full Name, Address of Check if

Home
Facility & Contact
Printed Name
Position /
Delivery
Number
and Contact No. Designation

Signature

License No
/ Expiry
Date

1
2
3

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.
CERTIFIED CORRECT:
Signature: __________________________________________________
Printed Name: ______________________________________________
Designation: ________________________________________________
License Number: ____________________________________________

Date: ___________________________

Expiry Date: _____________________

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to

me his/her Residence Certificate No. __________________________ issued at ______________________________ on _________ _____________________.
Affix Documentary Stamp
Administering
Officer or Notary Public
PRC FORM No.107-A
(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions
Name of Applicant: ______________________________
__________________________________

School:

Supervised by

Name and Address

of Patient

Case
No

Complete Diagnosis
(Gravida, Para)

Date & Time

Performed

Full Name, Address of Check if

Home
Facility & Contact
Printed Name
Position /
Delivery
Number
and Contact No. Designation

Signature

License No
/ Expiry
Date

1
2
3

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.
CERTIFIED CORRECT:
Signature: __________________________________________________
Printed Name: ______________________________________________
Designation: ________________________________________________
License Number: ____________________________________________

Date: ___________________________

Expiry Date: _____________________

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to

me his/her Residence Certificate No. __________________________ issued at ______________________________ on _________ _____________________.
Affix Documentary Stamp
Administering Officer or Notary Public