PRC FORM NO.

107 PROFESSIONAL REGULATION COMMISION

(Revised October 2010) Manila
Board of Midwifery
Record of Actual Intravenous Insertions
Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: ________________________________ School: UNIVERSITY OF CAGAYAN VALLEY
Name and Address of patient
Case
No.
Complete
Diagnosis
(Gravida_ Para_)
Date &
Time
Perform
Full Name, Address
of Facility & Contact
Number
Check
if Home
Del.
Supervised By:
Printed Name &
Contact No.
Position/
Designation
Signature
License
No. /Exp.
Date
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 the student midwives and affix their signature in this Form must present a Certificate of
Training on Intravenous Insertions to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.

Subscribed and sworn to me before this________________ at __________________ Affiant exhibiting
to me his/her Residence Certificate No. _______________ issued at _____________on_____________.
CERTIFIED CORRECT:
Signature: ______________________ Date:__________________
________________________________ Printed Name: _______________________________
Administering Officer or Notary Public Designation: _________________________________
Lic. No.: __________________ Expiry Date: _________________
Affix
Documentary Stamp
(to be posted on the last page)