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    New PRC Form Midwifery

    Uploaded by

    Jrr Estabaya Irang
    This document contains 3 forms that a midwife applicant must fill out as part of their application for licensure to the Professional Regulation Commission in the Philippines. The forms include records of actual deliveries handled, records of actual suturing of perineal lacerations, and records of actual intravenous insertions. For each procedure performed, the applicant must provide information such as the patient's name and details, diagnosis, date, location and details of the supervising midwife or nurse.

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    New PRC Form Midwifery

    Uploaded by

    Jrr Estabaya Irang
    17K views4 pages
    This document contains 3 forms that a midwife applicant must fill out as part of their application for licensure to the Professional Regulation Commission in the Philippines. The forms include records of actual deliveries handled, records of actual suturing of perineal lacerations, and records of actual intravenous insertions. For each procedure performed, the applicant must provide information such as the patient's name and details, diagnosis, date, location and details of the supervising midwife or nurse.

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    NEW FORM

    Original Title

    NEW PRC FORM MIDWIFERY

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    © Attribution Non-Commercial (BY-NC)

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    This document contains 3 forms that a midwife applicant must fill out as part of their application for licensure to the Professional Regulation Commission in the Philippines. The forms include records of actual deliveries handled, records of actual suturing of perineal lacerations, and records of actual intravenous insertions. For each procedure performed, the applicant must provide information such as the patient's name and details, diagnosis, date, location and details of the supervising midwife or nurse.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    17K views4 pages

    New PRC Form Midwifery

    Uploaded by

    Jrr Estabaya Irang
    This document contains 3 forms that a midwife applicant must fill out as part of their application for licensure to the Professional Regulation Commission in the Philippines. The forms include records of actual deliveries handled, records of actual suturing of perineal lacerations, and records of actual intravenous insertions. For each procedure performed, the applicant must provide information such as the patient's name and details, diagnosis, date, location and details of the supervising midwife or nurse.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    PRC FORM No.

    106 (Revised October 2010)

    PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Deliveries Handled Please Check: Graduate Midwife

    Registered Nurse

    Name of Applicant: JHAN ROBERT RAIE ESTABAYA IRANG


    Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performed Full Name, Address of Facility & Contact Number

    School: OUR LADY OF LOURDES COLLEGE FOUNDATION


    Check if Home Del. Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration Date

    1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

    (Continued at the Back)

    Name and Address of Patient

    Case No.

    Complete Diagnosis (Gravida_Para_)

    Date & Time Performed

    Full Name, Address of Facility & Contact Number

    Check if Home Del.

    Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration 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 ___________________.
    CERTIFIED CORRECT:

    Affix
    Documentary Stamp (to be posted on the last page)

    Signature: ______________________ Date: ____________ Printed Name: o Designation: Principal/Asst. Dean/Clinical Coordinator o License Number: Expiry Date:

    PRC FORM No. 107 (Revised October 2010)

    PROFESSIONAL REGULATION COMMISION Manila BOARD OF MIDWIFERY Record of Actual Suturing of Perineal Laceration Please Check: Graduate Midwife

    Registered Nurse

    Name of Applicant: JHAN ROBERT RAIE ESTABAYA IRANG


    Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performed Full Name, Address of Facility & Contact Number

    School: OUR LADY OF LOURDES COLLEGE FOUNDATION


    Check if Home Del. Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration Date

    1.

    2.

    3.

    4.

    5.

    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 COMMISION Manila BOARD OF MIDWIFERY Record of Actual Intravenous Insertions School: OUR LADY OF LOURDES COLLEGE FOUNDATION

    Name of Applicant: JHAN ROBERT RAIE ESTABAYA IRANG

    Name and Address of Patient

    Case No.

    Complete Diagnosis (Gravida_Para_)

    Date & Time Performed

    Full Name, Address of Facility & Contact Number

    Check if Home Del.

    Supervised by: Printed Name & Contact No. Position/ Designation Signature License No./ Expiration Date

    1.

    2.

    3.

    4.

    5.

    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 SUBSCRIBED AND SWORN To before me this ____________________ at _____________________Affiant exhibiting to me his/her Residence Certificate No. _______________ issued at ________________________ on ___________________.
    CERTIFIED CORRECT:

    Affix
    Documentary Stamp (to be posted on the last page)

    Signature: ______________________ Date: ____________ Printed Name: Designation: Principal/Asst. Dean/Clinical Coordinator o License Number: Expiry Date:

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