PRC FORM No.

106
Republic of the Philippines
(Revised October 2010)
Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Deliveries Handled

Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

Date & CHECK SUPERVISED BY:

Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date
Joyce Sumiran PUFT-NSD July 2, 2022
1. 43556
2:18AM
Lopez Quezon G1P0

Mariel Durante PUFT-NSD July 2, 2022

2. 41000
3:09AM
Lopez Quezon G1P0

3. Leneth Rodrigueza
PUFT-NSD July 6, 2022
42585
Buenavista Quezon G1P0 1:08AM

Carlota Mirabuna PUFT-NSD July 6, 2022

4. 19101
Lopez Quezon G2P1 1:00AM

5. Arlene Rayna
PUFT-NSD
4058
Buenavista Quezon G7G6

Lerma Ramirez PUFT-NSD

6. 26324
Lopez Quezon G3P2

Aiza Bequillo PUFT-NSD

7. 38642
Lopez Quezon G1P0

BAbelyn Ramirez PUFT-NSD

8. 14570
Lopez Quezon G3P2

Mary joy Bestar PUFT-NSD

9. 43700
Tagkawayan Quezon G1P0

Cyril Armenta PUFT-NSD

10. 43463
Calauag Quezon G1P0
 Date & CHECK SUPERVISED BY:
Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date
Norean Manalo PUFT-NSD July 8, 2022
11.Tagkawayan Quezon 47355
G1G0 10:24PM

Melinda Nollora PUFT-NSD July 9, 2022

12. Calauag Quezon 4165
G4P3 6:00AM

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20.

NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.
2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. 7392.

SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. Affiant

exhibiting to me his/her Residence Certificate No. ____________ issued at _______________________ on ____________________.
CERTIFIED CORRECT:

Signature: ___________________ Date: ___________

Affix Printed Name: ________________________________
________________________________ Documentary Stamp Designation:__________________________________
(to be posted on the last page)
Administering Officer or Notary Public Lic. No.:_____________ Expiry Date:______________
 PRC FORM No. 107
Republic of the Philippines
(Revised October 2010)
Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Repair of Perineal Lacerations

Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

Date & CHECK SUPERVISED BY:

Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date

1.

2.

3.

4.

5.

(See back page)

 PRC FORM No. 107-A
Republic of the Philippines
(Revised October 2010)
Professional Regulation Commission
Lucena City

BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions

Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

Date & CHECK SUPERVISED BY:

Case Complete diagnosis Full name, address of
NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
No. (gravida_para_) facility & contact number Signature
Performed DELIVERY & contact No. Designation Expiration date

1.

2.

3.

4.

5.

NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.
2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. 7392.

SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. Affiant

exhibiting to me his/her Residence Certificate No. ____________ issued at _______________________ on ____________________.
CERTIFIED CORRECT:

Signature: ___________________ Date: ___________

Affix Printed Name: ________________________________
________________________________ Documentary Stamp Designation:__________________________________
(to be posted on the last page)
Administering Officer or Notary Public Lic. No.:_____________ Expiry Date:______________