PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY

PRC FORM No. 106

Record of Actual Deliveries Handled
(Revised January 2011)

Record of Actual Delivery Handled

Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: MARAMAG, JEL B. School: KALINGA STATE UNIVERSITY

Check if Supervised by
Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient Case No Home Printed Name and Position / License No /
(Gravida, Para) Performed & Contact Number Signature
Delivery Contact No. Designation Expiry Date
Aboc, Eva Marie Eva Marie, 31 years old,
02/23/2020 Kalinga Provincial Hospital Isaiah G. Patong RM/Clinical 0161615
31 17-3032 G2P2 (2002) PU 39 weeks,
7:02 AM P6, Bulanao, Tabuk City, Kalinga 09759378398 Instructor 04/17/25
Cudal, Tabuk City, Kalinga cephalic in labor, delivered
 Check if Supervised by
Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient Case No Home Printed Name and Position / License No /
(Gravida, Para) Performed & Contact Number Signature
Delivery Contact No. Designation Expiry Date
NSD to a live baby boy.
APGAR=9, BW=3,000 grams
Rural Health Unit-II Eve-Joy C. Sulca RM/Clinical 0147277
Calanan, Tabuk City, Kalinga 09970963950 Instructor 05/02/23

Rural Health Unit-I Geraldine L. LIwaliw RM/Clinical 015189

Dagupan, Tabuk City, Kalinga 09672536849 Instructor 05/28/24

Abundant Grace of God Anie B. Naag RM/Clinical 0152562

Maternity Clinic 09519189032 Instructor 03/15/22
Magsaysay, Tabuk City, Kalinga
Kalinga Provincial Hospital Nellie V. Apatas RM/Clinical 0123892
P6, Bulanao, Tabuk City, Kalinga 09354558861 Instructor 11/16/21

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor
 Check if Supervised by
Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient Case No Home Printed Name and Position / License No /
(Gravida, Para) Performed & Contact Number Signature
Delivery Contact No. Designation Expiry Date
RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor
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 actual suturing of perineal lacerations to the Board pursuant to Board
Resolution No. 100 s 1993, dated December 1, 1993.
CERTIFIED CORRECT:

Signature: ________________________________________________Date: ___________________________

Printed Name: ANIE B. NAAG, MPH
Designation: Program Chairman, Diploma in Midwifery
License Number: PRC LIC. 0152562 Expiry Date: 03-15-22

CP # 09519189032
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued
at ____________________________ on _______________________________.
Affix
Administering Officer or Notary Public
Documentary Stamp
to be posted on the last page
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY

PRC FORM No. 107

Record of Actual Deliveries Handled
(Revised January 2011)

Record of Actual Suturing of Lacerations Handled

Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: _____________________________ School: KALINGA STATE UNIVERSITY

Date & Check if Supervised by

Complete Diagnosis Full Name, Address of Facility
Name and Address of Patient Case No (Gravida, Para)
Time
& Contact Number
Home Printed Name and Position / License No /
Performed Delivery Signature
Contact No. Designation Expiry Date
Bardang, 25 years old, 09/04/18 Kalinga Provincial Hospital RM/Clinical
G2P2 (2002), PU 39 weeks, P6, Bulanao, Tabuk City, Kalinga Instructor
cephalic in labor, delivered
 Date & Check if Supervised by
Complete Diagnosis Full Name, Address of Facility
Name and Address of Patient Case No (Gravida, Para)
Time
& Contact Number
Home Printed Name and Position / License No /
Performed Delivery Signature
Contact No. Designation Expiry Date
NSD to a live baby boy,
Apgar=8, BW=3100 grams
w/ 1st degree at vaginal
mucosa, suturing done
Bardang, 25 years old,
G2P2 (2002), PU 39 weeks,
cephalic in labor, delivered
RM/Clinical
NSD to a live baby boy,
Instructor
Apgar=8, BW=3100 grams
w/ 2st degree at vaginal
mucosa, suturing done
RM/Clinical
Instructor

RM/Clinical
Instructor

RM/Clinical
Instructor
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 actual suturing of perineal lacerations to the Board pursuant to Board
Resolution No. 100 s 1993, dated December 1, 1993.
CERTIFIED CORRECT:

Signature: ________________________________________________Date: ___________________________

Printed Name: ANIE B. NAAG, MPH
Designation: Program Chairman, Diploma in Midwifery
License Number: PRC LIC. 0152562 Expiry Date: 03-15-22

CP #: 09519189032
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at
______________________________ on _______________________________.
Affix
Administering Officer or Notary Public Documentary Stamp
to be posted on the last page
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY

PRC FORM No. 107-A

Record of Actual Deliveries Handled
(Revised January 2011)

Record of Actual Intravenous Insertions

Please check if applicant is:

Graduate Midwife Registered Nurse

Name of Applicant: __________________________ School: KALINGA STATE UNIVERSITY

Check if Supervised by
Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient Case No (Gravida, Para) Performed & Contact Number
Home Printed Name and Position / License No /
Delivery Signature
Contact No. Designation Expiry Date
Bardang, 32 years old 09/30/19 Kalinga Provincial Hospital Isaiah G. Patong RM/Clinical
G3P3(3003), PU 40 3:00 PM P6, Bulanao, Tabuk City, Kalinga 09759378398 Instructor
 Check if Supervised by
Complete Diagnosis Date & Time Full Name, Address of Facility
Name and Address of Patient Case No (Gravida, Para) Performed & Contact Number
Home Printed Name and Position / License No /
Delivery Signature
Contact No. Designation Expiry Date
weeks, cephalic , NSD to
a live baby girl,
BW=3200 grams
Post Partum Hemorrhage
Bardang, 32 years old Kalinga Provincial Hospital
G3P3(3003), PU 40 P6, Bulanao, Tabuk City, Kalinga
weeks, cephalic , NSD to 0161615
a live baby girl, 04/17/23
BW=3200 grams
Meconium Stained
Bardang, 32 years old Kalinga Provincial Hospital
G3P3(3003), PU 40 P6, Bulanao, Tabuk City, Kalinga
weeks, cephalic , NSD to
a live baby girl,
BW=3200 grams
Prolong Labor
Bardang, 32 years old Kalinga Provincial Hospital
NO HAAN PAY NAGANAK G3P2(2002), PU 40 P6, Bulanao, Tabuk City, Kalinga
weeks, cephalic in labor
Rural Health Unit-I
Dagupan, Tabuk City, Kalinga

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 actual suturing of perineal lacerations to the Board pursuant to Board
Resolution No. 100 s 1993, dated December 1, 1993.
CERTIFIED CORRECT:

Signature: ________________________________________________Date: ___________________________

Printed Name: ANIE B. NAAG, MPH
Designation: Program Chairman, Diploma in Midwifery
License Number: PRC LIC. 0152562 Expiry Date: 03-15-22

CP #: 09519189032
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence Certificate No. __________________________ issued at
______________________________ on _______________________________.
Affix
Administering Officer or Notary Public Documentary Stamp
to be posted on the last page