PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY

Record of Actual Deliveries Handled

 PRC FORM No. 106
(Revised January 2011)
Record of Actual Delivery Handled
Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: __ZAMORA JOYLIZA________ School: Governor Alfonso D. Tan College

Check if Supervised by
Case Complete Diagnosis Date & Time Full Name, Address of Facility &
Name and Address of Patient (Gravida, Para) Performed Contact Number
Home Printed Name and Position / License No /
No Delivery Signature
Contact No. Designation Expiry Date
1 Boniao Jocelyn Doña Maria D.Tan
Purok-4 Mantic Tangub City Gravida4 Para4 Delivered
6-24-18 Memorial Hospital HAROLD ANO-OS RUDINAS
055969 spontaneously to a live Clinical Instructor
baby girl BW 2.7kgs
6’:05am Mantic Tangub City 09177554530
09461569419
2 Gutierez Mary Grace Doña Maria D.Tan
Purok-4 Demetrio Fernan Bonifacio Gravida 2 Para 2 Delivered
6-25-18 Memorial Hospital CRISTELY CUBIO MACA
Misamis Occidental 091202 spontaneously to a live Clinical Instructor
baby girl BW 3.2kgs
6:50am Mantic Tangub City 09078033487
09461569419
3 Ostia Rodelyn Doña Maria D.Tan
Purok 7 Tugas Tangub city Gravida 2 Para 2 Delivered
9-12-18 Memorial Hospital CRISTELY CUBIO MACA
123136 spontaneously to a live Clinical Instructor
term baby girl BW2.8kgs
8:50pm Mantic Tangub City 09078033487
09461569419
4 Lucresia Jean Doña Maria D.Tan
Purok 6 Bocator Tangub City Gravida 2 para 2 Delivetred
9-13-18 Memorial Hospital HAROLD ANO-OS RUDINAS
133526 spontaneously to a live Clinical Instructor
term baby girl BW3.2kgs
1:50pm Mantic Tangub City 09177554530
09461569419
5 Tomarong Irene S. Doña Maria D.Tan
Purok 4 Bintana Tangub City Gravida 1 Para1 Delivered
10-22-18 Memorial Hospital HAROLD ANO-OS RUDINAS
134490 spontaneously to a liver Clinical Instructor
term baby boy BW2.5kgs
9:48 pm Mantic Tangub City 09177554530
09461569419
6 Tacling Jayfe A. Doña Maria D.Tan
Gravida 1 Para 1 Delivered
Purok 5 Isidro D. Tan Tangub City 11-12-18 Memorial Hospital CRISTELY CUBIO MACA
137591 spontaneously to a live
3:05am Mantic Tangub City 09078033487 Clinical Instructor
term baby boy BW2.5kgs
09461569419
7 Biolongo Arlyn H, Doña Maria D.Tan
Purok 3 Paiton Tangub City Gravida 3 Para 3 Delivered
11-13-18 Memorial Hospital HAROLD ANO-OS RUDINAS
093207 spontaneously to a live
7:44pm Mantic Tangub City 09177554530
Clinical Instructor
term baby girl BW 3.2kgs
09461569419
8 Malig-on Decevel P. Doña Maria D.Tan
Gravida 3 Para 3 Delivered
Purok 3 Barangay IV Tangub City 11-17-18 Memorial Hospital CRISTELY CUBIO MACA
135456 spontaneously to a live
3:35pm Mantic Tangub City 09078033487
Clinical Instructor
term baby girl BW2.7kgs
09461569419
9 Padigos Merlyn E. Gravida 9 Para 6 Term 5
Doña Maria D.Tan
Purok 7 Silangit Tangub City Preterm 1 Abortion 2 Living
11-18-18 Memorial Hospital HAROLD ANO-OS RUDINAS
135470 5 Delivered spontaneousl to
4:20pm Mantic Tangub City 09177554530
Clinical Instructor
alive term baby girl
09461569419
BW1.5kgs
 Check if Supervised by
Case Complete Diagnosis Date & Time Full Name, Address of Facility &
Name and Address of Patient (Gravida, Para) Performed Contact Number
Home Printed Name and Position / License No /
No Delivery Signature
Contact No. Designation Expiry Date
10 Aljas Novelyn B.
Gravida 5 Para 5 Delivered
Doña Maria D.Tan Clinical Instructor
Purok 6 Catagan Tangub City 11-19-18 Memorial Hospital CRISTELY CUBIO MACA
135453 spontaneously to a live
11:30 Mantic Tangub City 09078033487
term baby girl
09461569419
11 Manulong Jay-ann C. Doña Maria D.Tan
Purok 2 Digson Bonifacio Misamis
Gravida 3 Para 2 Delivered
11-23-18 Memorial Hospital HAROLD ANO-OS RUDINAS
(continued next page)
Occidental
135520 spontaneously to live birth
3:50pm Mantic Tangub City 09177554530
Clinical Instructor
baby boy BW3.1kgs
09461569419
12 Mejia Grace Gravida 2 Para 2 Delivered Doña Maria D.Tan
Purok 1 Minsubong Tangub city spontaneously to a live 11-27-18 Memorial Hospital HAROLD ANO-OS RUDINAS
135564
term birth baby boy 9:32pm Mantic Tangub City 09177554530 Clinical Instructor
BW2.6kgs 09461569419
13 Arnaiz Glarie L. Doña Maria D.Tan
Gravida 3 Para 2 Abortion 1
Purok 5 Panalsalan Tangub City 11-19-18 Memorial Hospital CRISTELY CUBIO MACA
135588 Delivered spontaneously to
1:58pm Mantic Tangub City 09078033487
Clinical Instructor
a live term baby boy BW2.8
09461569419
14 Ore Julieta M Doña Maria D.Tan
Gravida 1 Para 1 Delivered
Purok 1 Bintana Tangub City 11-30-18 Memorial Hospital CRISTELY CUBIO MACA
135598 spontaneously to a live
5:53pm Mantic Tangub City 09078033487
Clinical Instructor
term baby girl BW4kgs
09461569419
15 Gallano Lesriel Doña Maria D.Tan
Gravida 1 Para 1 Delivered
Purok Maaba Migcanaway Tangub City 12-19-18 Memorial Hospital HAROLD ANO-OS RUDINAS
136167 spontaneously to a live
5:30pm Mantic Tangub City 09177554530 Clinical Instructor
term baby boy BW2.9kgs
09461569419
16 Campos Emely Q Doña Maria D.Tan
Gravida 1Para 1 Delivered
Purok 1 Hoyohoy Tangub City 12-20-18 Memorial Hospital HAROLD ANO-OS RUDINAS
136179 spontaneously to a live
5:30pm Mantic Tangub City 09177554530
Clinical Instructor
birth baby girl BW2.5kgs
09461569419
17 Lanataca Mary Jean Doña Maria D.Tan
Gravida 7 Para 7 Delivered
Purok3 Sinusa Tangun City 12-21-18 Memorial Hospital CRISTELY CUBIO MACA
139730 spontaneously to a live
3:00pm Mantic Tangub City 09078033487
Clinical Instructor
term baby girl BW3.7kgs
09461569419
18 Yosores Gretchen Doña Maria D.Tan
Gravida 4Para 4 Delivered
Purok 4 Garang Tangub City 12-30-18 Memorial Hospital HAROLD ANO-OS RUDINAS
057684 spontaneously to a live
6:50pm Mantic Tangub City 09177554530
Clinical Instructor
term baby boy BW3.3kgs
09461569419
19 Pitogo, Chrisjel Doña Maria D.Tan
Gravida 4Para 4 Delivered
Purok 3 Tituron, Tangub City 2-10-19 Memorial Hospital CRISTELY CUBIO MACA
096213 spontaneously to a live
3:19pm Mantic Tangub City 09078033487 Clinical Instructor
term baby boy BW3.5kgs
09461569419
Doña Maria D.Tan
Gravida e Para 3 Delivered
20 Lomo Mailyn 2-24-19 Memorial Hospital CRISTELY CUBIO MACA
Purok 3 Capucao Ozamiz City
117986 spontaneously to a live
5:50am Mantic Tangub City 09078033487
Clinical Instructor
term baby girl BW3.8kgs
09461569419
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 _______________________________. CERTIFIED CORRECT:

Affix Signature: __________________________________________________ Date: ___________________________

Documentary Stamp Printed Name: JAY STEPHEN C. MONDONG, RN,RM,MN
to be posted on the last page Designation: PRINCIPAL
License Number: Expiry Date :
Administering Officer or Notary Public
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY

Record of Actual Deliveries Handled

 PRC FORM No. 107
(Revised January 2011)

Record of Actual Suturing of Lacerations Handled

Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: ________________________________________ School: Governor Alfonso D. Tan College

Check if Supervised by
Case Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient (Gravida, Para) Performed & Contact Number
Home Printed Name and Position / License No /
No Delivery Signature
Contact No. Designation Expiry Date
1 Tomarong Irene S. Gravida 1 Para1 Doña Maria D.Tan
Purok 4 Bintana Tangub City Delivered spontaneously 10-22-18 Memorial Hospital HAROLD ANO-OS RUDINAS Clinical
134490
to a live term baby boy 9:48 pm Mantic Tangub City 09177554530 Instructor
BW2.5kgs 09461569419
2 Tacling Jayfe A. Gravida 1 Para 1 Doña Maria D.Tan
Purok 5 Isidro D. Tan Tangub City Delivered spontaneously 11-12-18 Memorial Hospital CRISTELY CUBIO MACA Clinical
137591
to a live term baby boy 3:05am Mantic Tangub City 09078033487 Instructor
BW2.5kgs 09461569419
3 Ore Julieta M Gravida 1 Para 1 Doña Maria D.Tan
Purok 1 Bintana Tangub City Delivered spontaneously 11-30-18 Memorial Hospital CRISTELY CUBIO MACA Clinical
135598
to a live term baby girl 5:53pm Mantic Tangub City 09078033487 Instructor
BW4kgs 09461569419
4 Gallano Lesriel Gravida 1 Para 1 Doña Maria D.Tan
Purok Maaba Migcanaway Tangub City Delivered spontaneously 12-19-18 Memorial Hospital HAROLD ANO-OS RUDINAS Clinical
136167
to a live term baby boy 5:30pm Mantic Tangub City 09177554530 Instructor
BW2.9kgs 09461569419
5 Campos Emely Q Gravida 1Para 1 Doña Maria D.Tan
Purok 1 Hoyohoy Tangub City Delivered spontaneously 12-20-18 Memorial Hospital HAROLD ANO-OS RUDINAS Clinical
136179
to a live birth baby girl 5:30pm Mantic Tangub City 09177554530 Instructor
BW2.5kgs 09461569419
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 _______________________________.
CERTIFIED CORRECT:

Affix Signature: __________________________________________________ Date: ___________________________

Documentary Stamp Printed Name: : JAY STEPHEN C. MONDONG, RN,RM,MN
Administering Officer or Notary Public to be posted on the last page Designation: PRINCIPAL
License Number: Expiry Date :
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY

Record of Actual Deliveries Handled

 PRC FORM No. 107-A
(Revised January 2011)

Record of Actual Intravenous Insertions

Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: ________________________________________ School: Governor Alfonso D. Tan College

Check if Supervised by
Case Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient (Gravida, Para) Performed & Contact Number
Home Printed Name and Position / License No /
No Delivery Signature
Contact No. Designation Expiry Date
1 Boniao Jocelyn Gravida4 Para4 Doña Maria D.Tan
Purok-4 Mantic Tangub City Delivered spontaneously 6-24-18 Memorial Hospital HAROLD ANO-OS RUDINAS Clinical
055969
to a live baby girl BW 6’:05am Mantic Tangub City 09177554530 Instructor
2.7kgs 09461569419
2 Gutierez Mary Grace Gravida 2 Para 2 Doña Maria D.Tan
Fernan Bonifacio Misamis Occidental Delivered spontaneously 6-25-18 Memorial Hospital CRISTELY CUBIO MACA Clinical
091202
to a live baby girl BW 6:50am Mantic Tangub City 09078033487 Instructor
3.2kgs 09461569419
3 Ostia Rodelyn Gravida 2 Para 2 Doña Maria D.Tan
Purok 7 Tugas Tangub city Delivered spontaneously 9-12-18 Memorial Hospital CRISTELY CUBIO MACA Clinical
123136
to a live term baby girl 8:50pm Mantic Tangub City 09078033487 Instructor
BW2.8kgs 09461569419
4 Lucresia Jean Gravida 2 para 2 Doña Maria D.Tan
Purok 6 Bocator Tangub City Delivetred 9-13-18 Memorial Hospital HAROLD ANO-OS RUDINAS Clinical
133526
spontaneously to a live 1:50pm Mantic Tangub City 09177554530 Instructor
term baby girl BW3.2kgs 09461569419
5 Biolongo Arlyn H, Gravida 3 Para 3 Doña Maria D.Tan
Purok 3 Paiton Tangub City Delivered spontaneously 11-13-18 Memorial Hospital HAROLD ANO-OS RUDINAS Clinical
093207
to a live term baby girl 7:44pm Mantic Tangub City 09177554530 Instructor
BW 3.2kgs 09461569419
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 _______________________________.
CERTIFIED CORRECT:

Affix Signature: __________________________________________________ Date: ___________________________

Documentary Stamp Printed Name: JAY STEPHEN C. MONDONG, RN,RM,MN
Administering Officer or Notary Public to be posted on the last page Designation: PRINCIPAL
License Number: Expiry Date :