PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY
(continued next page)
Record of Actual Delivery Handled


Name of Applicant: ESTRELLA, SAM ANGELO F.
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
Signature
License No /
Expiry Date
1

2

3

4

5

6

7

8

9

10

Please check if applicant is:
Graduate Midwife Registered Nurse
PRC FORM No. 106
(Revised January 2011)
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
Signature
License No /
Expiry Date
11

12

13

14

15

16

17

18

19

20

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

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her
Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.

Administering Officer or Notary Public
Affix
Documentary Stamp
to be posted on the last page
CERTIFIED CORRECT:
Signature: __________________________________________________ Date: ___________________________
Printed Name: OFELIA O. VALDEHUEZA
Designation: Director-Institute of Community Health and Allied Medical Sciences
License Number: 0108054 Expiry Date : Renewal on process mito 2011
PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Lacerations Handled

Name of Applicant: ESTRELLA, SAM ANGELO F.
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
Signature
License No /
Expiry Date
1

2

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.
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her
Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.

Administering Officer or Notary Public
PRC FORM No. 107
(Revised January 2011)
Please check if applicant is:
Graduate Midwife Registered Nurse
Affix
Documentary Stamp
to be posted on the last page
CERTIFIED CORRECT:
Signature: __________________________________________________ Date: ___________________________
Printed Name: OFELIA O. VALDEHUEZA
Designation: Director-Institute of Community Health and Allied Medical Sciences
License Number: 0108054 Expiry Date : Renewal on process mito 2011
PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertions

Name of Applicant: ESTRELLA, SAM ANGELO F.
Name and Address of Patient
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time
Performed
Full Name, Address of Facility
& Contact Number
Check if
Home
Delivery
Supervised by
Printed Name and
Contact No.
Position /
Designation
Signature
License No /
Expiry Date
1

2

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.
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her
Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.

Administering Officer or Notary Public
PRC FORM No. 107-A
(Revised January 2011)
Please check if applicant is:
Graduate Midwife Registered Nurse
Affix
Documentary Stamp
to be posted on the last page
CERTIFIED CORRECT:
Signature: __________________________________________________ Date: ___________________________
Printed Name: OFELIA O. VALDEHUEZA
Designation: Director-Institute of Community Health and Allied Medical Sciences
License Number: 0108054 Expiry Date : Renewal on process mito 2011