PRC FORM No. 106(Revised October 2010)PROFESSIONAL REGULATION COMMISIONManilaBOARD OF MIDWIFERYRecord of Actual Deliveries HandledPlease Check: Graduate Midwife Registered Nurse

Name of Applicant: Josephine M. Rivera School: University of the Philippines- Manila, School of Health Sciences

Name and Address of PatientCase No.Complete Diagnosis(Gravida_Para_)Date & Time PerformedFull Name, Address of Facility & Contact NumberCheck if Home Del.Supervised by:

Printed Name & Contact No.Position/ DesignationSignatureLicense No./Expiration Date

1. RIA MAE ROTAQUIO LEONES, BRGY. NONONG, SAN LUIS, AURORA141114

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Name and Address of PatientCase No.Complete Diagnosis(Gravida_Para_)Date & Time PerformedFull Name, Address of Facility & Contact NumberCheck if Home Del.Supervised by:

Printed Name & Contact No.Position/ DesignationSignatureLicense No./Expiration Date

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

CERTIFIED CORRECT:Signature: ______________________ Date: ____________Printed Name: ALICIA D. NUYDA, RM, RN, MAN oDesignation: Principal/Asst. Dean/Clinical Coordinator oLicense Number: 0094571 Expiry Date: August 3, 2013SUBSCRIBED AND SWORN To before me this ____________________ at _____________________Affiant exhibiting to me his/her Residence Certificate No. _______________ issued at ________________________ on ___________________.

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PRC FORM No. 107(Revised October 2010)PROFESSIONAL REGULATION COMMISIONManilaBOARD OF MIDWIFERYRecord of Actual Suturing of Perineal LacerationPlease Check: Graduate Midwife Registered Nurse

Name of Applicant: _______________________________________________School: CAMARINES SUR POLYTECHNIC COLLEGES

Name and Address of PatientCase No.Complete Diagnosis(Gravida_Para_)Date & Time PerformedFull Name, Address of Facility & Contact NumberCheck if Home Del.Supervised by:

Printed Name & Contact No.Position/ DesignationSignatureLicense No./Expiration Date

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Note:1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.2) Registered Midwives/Clinical Instructors who supervise student midwives and affix their signature in this Form must present Certificate of Training on Suturing of Perineal lacerations to the Board pursuant to Board Resolutions No. 100, Series of 1993, dated December 1,1993

(See back page)

PRC FORM No. 107-A(Revised October 2010)PROFESSIONAL REGULATION COMMISIONManilaBOARD OF MIDWIFERYRecord of Actual Intravenous Insertions

Name of Applicant: _______________________________________________School: CAMARINES SUR POLYTECHNIC COLLEGES

Name and Address of PatientCase No.Complete Diagnosis(Gravida_Para_)Date & Time PerformedFull Name, Address of Facility & Contact NumberCheck if Home Del.Supervised by:

Printed Name & Contact No.Position/ DesignationSignatureLicense No./Expiration Date

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Note:1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor.2) Registered Midwives/Clinical Instructors who supervise student midwives and affix their signature in this Form must present Certificate of Training on Suturing of Perineal lacerations to the Board pursuant to Board Resolutions No. 100, Series of 1993, dated December 1,1993

CERTIFIED CORRECT:Signature: ______________________ Date: ____________Printed Name: ALICIA D. NUYDA, RM, RN, MAN oDesignation: Principal/Asst. Dean/Clinical Coordinator oLicense Number: 0094571 Expiry Date: August 3, 2013SUBSCRIBED AND SWORN To before me this ____________________ at _____________________Affiant exhibiting to me his/her Residence Certificate No. _______________ issued at ________________________ on ___________________.

AffixDocumentary Stamp(to be posted on the last page)