PRC FORM No.

106 (Revised January 2011)

PROFESSIONAL REGULATION COMMISSION Manila

BOARD OF MIDWIFERY Record of Actual Deliveries Handled

Name of Applicant: MARICON A. BARTOLO

Name and Address of Patient
1.Amelyn Rona Tano Ligtong 3, Rosario Cavite

School: Dr. Jose Fabella Memorial Hospital

Date & Time Performed

Case No

Complete Diagnosis (Gravida, Para)

Full Name, Address of Facility & Contact Number

Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

400426

Name and Address of Patient

11

Case No

Complete Diagnosis (Gravida, Para)

G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an

Date & Time Performed

Full Name, Address of Facility & Contact Number

Supervised by
Check if Home Delivery

Printed Name and Contact No.

Position / Designation

Signature

License No / Expiry Date

12

13

alive baby girl. 14 G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by

15

16

17

18

NSD to an alive baby girl. 19 G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl.

20

Note:

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

CERTIFIED CORRECT: Signature: __________________________________________________ Printed Name: Designation: License Number: Expiry Date : Date: ___________________________

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at ______________________________ on _______________________________.
Affix Documentary Stamp
to be posted on the last page

Administering Officer or Notary Public

PRC FORM No. 107

(Revised January 2011)

PROFESSIONAL REGULATION COMMISSION Manila

BOARD OF MIDWIFERY

Record of Actual Suturing of Lacerations Handled

Name of Applicant: Bautista, Carlo G.

Name and Address of Patient Case No
Complete Diagnosis (Gravida, Para)
G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. 2 G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl.

School: Dr. Jose Fabella Memorial Hospital

Date & Time Performed

Full Name, Address of Facility & Contact Number

Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl.

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: Expiry Date : Date: ___________________________

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at ______________________________ on _________ _____________________.
Affix Documentary Stamp
to be posted on the last page

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: Bautista Carlo G

Name and Address of Patient
1

School: Dr. Jose Fabella Memorial Hospital

Date & Time Performed

Case No

Complete Diagnosis (Gravida, Para)

G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl. G4P4 (4004) Pregnancy Uterine 38 weeks, Age Of Gestation, Cephalic, delivered by NSD to an alive baby girl.

Full Name, Address of Facility & Contact Number

Check if Home Delivery

Printed Name and Contact No.

Supervised by Position / Signature Designation

License No / Expiry Date

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
(to be posted on the last page)

Administering Officer or Notary Public