PRC FORM No.

106 PROFESSIONAL REGULATION COMMISION

(Revised October 2010) Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: JOYVIE LEEN D. CABALLES School: BALIAN COMMUNITY COLLEGE

Chec Supervised by:

Full Name, Address of
Case Complete Diagnosis Date & Time k if
Name and Address of Patient Facility & Contact Printed Name & Position/ License No./
No. (Gravida_Para_) Performed Home Signature
Number Contact No. Designation Expiration Date
Del.
1. CHERLY G. BELOAN G3P3 Pregnancy Uterine 40 weeks. Age of Laguna Medical Center MRS. ROSARIO D. 0053439
Brgy. Dayap, Caluan, Laguna 164344 Gestation. Delivered a term cephalic to an alive 01-04-18 J. De Leon St. Sta-Cruz OARGA CLINICAL 5-14--2020
baby boy. After 5 minutes APGAR SCORE of 9
taken. Birth weight 3500grams by Normal 4:50 PM Laguna 09177097408 INSTRUCTOR
Spontaneous Delivery. 543-3333 RM
2. DONA MAE MALACAPO G3P3 Pregnancy Uterine 40 weeks. Age of Laguna Medical Center MRS. JEANY A. CLINICAL 0027164
Brgy. Masapang, Victoria, Laguna 164354 Gestation. Delivered a term cephalic to an alive 1-05-18 J. De Leon St. Sta-Cruz AMBROCIO INSTRUCTOR 9-22-2020
baby boy. After 5 minutes APGAR SCORE of 9
taken. Birth weight 2,500 grams by Normal 11:14 AM Laguna 09062101758 RM
Spontaneous Delivery. 543-3333
3. JUDY KATE REGONDOLA 164413 G2P2 Pregnancy Uterine 40 weeks. Age of 01-05-18 Laguna Medical Center MRS. JEANY A. CLINICAL 0027164
Brgy. Calios, Sta. Cruz Laguna Gestation. Delivered a term cephalic to an alive 7:15 PM J. De Leon St. Sta-Cruz AMBROCIO INSTRUCTOR 9-22-2020
baby girl. After 5 minutes APGAR SCORE of 9
taken. Birth weight 2500grams by Normal Laguna 09062101758 RM
Spontaneous Delivery. 543-3333
4.DIANNE HEMY AGBAYANI 166255 G3P3 Pregnancy Uterine 39 1/7 weeks. Age of 2-21-18 Laguna Medical Center MRS. ROSARIO D. CLINICAL 0053439
Brgy. Lumot, Caluan,Laguna Gestation. Delivered a term cephalic to an alive 8:51 PM J. De Leon St. Sta-Cruz OARGA INSTRUCTOR 5-14--2020
baby girl. After 5 minutes APGAR SCORE of 9
taken. Birth weight 2800grams by Normal Laguna 09177097408 RM
Spontaneous Delivery. 543-3333
5.LUIZA LEGASPI 166672 G3P3 Pregnancy Uterine 39weeks. Age of 03-02-18 Laguna Medical Center MRS. ROSARIO D. CLINICAL 0053439
Brgy. BUboy, Pagsanjan, Laguna Gestation. Delivered a term cephalic to an alive 12:00 PM J. De Leon St. Sta-Cruz OARGA INSTRUCTOR 5-14--2020
baby girl. After 5 minutes APGAR SCORE of 9
taken. Birth weight 2800grams by Normal Laguna 09177097408 RM
CLINICAL INSTRUCTOR 543-3333
RM Spontaneous Delivery.
6. ROSE MARIE TULING 169076 G3P3 Pregnancy Uterine 39weeks. Age of 05-04-18 Laguna Medical Center MRS.CORAZON A. CLINICAL 0030720
Brgy. Palina, Nagcarlan, Laguna Gestation. Delivered a term cephalic to an alive 1:24 AM J. De Leon St. Sta-Cruz CAUSAPIN INSTRUCTOR 09-26-2019
baby girl. After 5 minutes APGAR SCORE of 9
taken. Birth weight 2800grams by Normal Laguna 09422672790 RM
Spontaneous Delivery. 543-3333
7.REA MAGRACIA 171029 G2P2 Pregnancy Uterine 39 weeks. Age of 6-26-18 Laguna Medical Center MRS. JEANY A. CLINICAL 0027164
Brgy. Buenavista, Magdalena, Gestation. Delivered a term cephalic to an alive 4:20 PM J. De Leon St. Sta-Cruz AMBROCIO INSTRUCTOR 9-22-2020
baby girl. After 5 minutes APGAR SCORE of 9
Laguna taken. Birth weight 3200grams by Normal Laguna 09062101758 RM
Spontaneous Delivery. 543-3333
8.MARY JANE ABU 171329 G4P4 Pregnancy Uterine 40 weeks. Age of 07-02-18 Laguna Medical Center MRS. JEANY A. CLINICAL 0027164
Brgy.Dingin,Pagsanjan, Gestation. Delivered a term cephalic to an alive 4:25 PM J. De Leon St. Sta-Cruz AMBROCIO INSTRUCTOR 9-22-2020
baby boy. After 5 minutes APGAR SCORE of 9
Laguna taken. Birth weight 3400grams by Normal Laguna 09062101758 RM
Spontaneous Delivery. 543-3333
9.MILLETTE E. MANACNOL 171561 G3P3 Pregnancy Uterine 39 weeks. Age of 07-10-18 Laguna Medical Center MRS. JEANY A. CLINICAL 0027164
Brgy. San Antonio,Los Banos Gestation. Delivered a term cephalic to an alive 6:15 PM J. De Leon St. Sta-Cruz AMBROCIO INSTRUCTOR 9-22-2020
baby girl. After 5 minutes APGAR SCORE of 9
Laguna taken. Birth weight 3200grams by Normal Laguna 09062101758 RM
Spontaneous Delivery. 543-3333
10.JUDY ANNE ABRENILLA 174492 G3P3 Pregnancy Uterine 40 weeks. Age of 09-23-18 Laguna Medical Center MRS.CORAZON A. CLINICAL 0030720
Brgy. Malinta,Los Banos,Laguna Gestation. Delivered a term cephalic to an alive 7:22 PM J. De Leon St. Sta-Cruz CAUSAPIN INSTRUCTOR 09-26-2019
baby girl. After 5 minutes APGAR SCORE of 9 Laguna 09422672790 RM
taken. Birth weight 3000grams by Normal
Spontaneous Delivery. 543-3333

Check if Supervised by:

Complete Diagnosis Date & Time Full Name, of Facility
Name and Address of Patient Case No. Home Printed Name & Contact Position/ License No./
(Gravida_Para_) Performed & Contact Number Signature
Del. No. Designation Expiration Date
11.CINDY MEJIA G2P2 Pregnancy Uterine 39
Brgy. Patimbao, Sta. Cruz Laguna weeks. Age of Gestation. 10-07-18 Laguna Medical Center MRS. JEANY A. AMBROCIO CLINICAL 0027164
Delivered a term cephalic to an
alive baby boy. After 5 minutes 5:16 AM J. De Leon St. Sta-Cruz 09062101758 INSTRUCTOR 9-22-2020
APGAR SCORE of 9 taken. Birth Laguna RM
weight 3300grams by Normal 543-3333
Spontaneous Delivery.
12.MARY ANNE PALACAY 175644 G4P4 Pregnancy Uterine 40 10-22-18
Brgy. Bubukal, Sta. Cruz Laguna weeks. Age of Gestation. 12:40 AM Laguna Medical Center MRS. ROSARIO D. OARGA CLINICAL 0053439
Delivered a term cephalic to an
alive baby boy. After 5 minutes J. De Leon St. Sta-Cruz 09177097408 INSTRUCTOR 5-14-2020
APGAR SCORE of 9 taken. Birth Laguna RM
weight 2900 grams by Normal 543-3333
Spontaneous Delivery.
13.RUBELYN T. DINGLASAN 176509 G2P2 Pregnancy Uterine 40 2/7 11-12-18
Brgy. Tranca, Bay Laguna weeks. Age of Gestation. 4:45 PM Laguna Medical Center MRS.CORAZON A. CLINICAL 0030720
Delivered a term cephalic to an
alive baby girl. After 5 minutes J. De Leon St. Sta-Cruz CAUSAPIN INSTRUCTOR 09-26-2019
APGAR SCORE of 9 taken. Birth Laguna 09422672790 RM
weight 3100grams by Normal 543-3333
Spontaneous Delivery.
14. ROSE ANNE REYES 176784 G3P3 Pregnancy Uterine 41 11-19-18
Brgy. Calios, Sta. Cruz Laguna weeks. Age of Gestation. 1:54 PM Laguna Medical Center MRS.CORAZON A. CLINICAL 0030720
Delivered a term cephalic to an
alive baby girl. After 5 minutes J. De Leon St. Sta-Cruz CAUSAPIN INSTRUCTOR 09-26-2019
APGAR SCORE of 9 taken. Birth Laguna 09422672790 RM
weight 3300grams by Normal 543-3333
Spontaneous Delivery.
15.VERONICA MARTINEZ 176796 G3P3 Pregnancy Uterine 40 11-19-18
Brgy.Duhat,Cavinti,Laguna weeks. Age of Gestation. 5:27 PM Laguna Medical Center MRS.CORAZON A. CLINICAL 0030720
Delivered a term cephalic to an
alive baby girl. After 5 minutes J. De Leon St. Sta-Cruz CAUSAPIN INSTRUCTOR 09-26-2019
APGAR SCORE of 9 taken. Birth Laguna 09422672790 RM
weight 2900grams by Normal 543-3333
Spontaneous Delivery.
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 Laceration to the Board pursuant
To Board Resolutions No. 100, Series of 1993, dated December 1, 1993

CERTIFIED CORRECT:
Affix
Documentary Stamp Signature: ______________________ Date: ____________
SUBSCRIBED AND SWORN To before me this (to be posted on the last page) Printed Name: o
____________________ at _____________________Affiant
Designation: o
exhibiting to me his/her Residence Certificate No. _______________
License Number: Expiry Date:
issued at ________________________ on ___________________.

PRC FORM No. 107-A PROFESSIONAL REGULATION COMMISION

(Revised October 2010) Manila
BOARD OF MIDWIFERY

Record of Actual Intravenous Insertions

Name of Applicant: JOYVIE LEEN D. CABALLES School: BALIAN COMMUNITY COLLEGE

Check Supervised by:

Date & Full Name,
Name and Address of Case Complete Diagnosis if License No./
Time Address of Facility Printed Name & Position/
Patient No. (Gravida_Para_) Home Signature Expiration
Performed & Contact Number Contact No. Designation
Del. Date
1.REYLEEN G. CONJE 172439 G8P7;Cephalic in 8-1-18 Laguna Medical Center MRS. JEANY A. CLINICAL
East,Talaongan, Labor: Multigravida; 9:22 AM 0027164
J. De Leon St. Sta-Cruz AMBROCIO INSTRUCTOR
Cavinti,Laguna 39 weeks Age of Laguna 9-22-2020
Gestation 09062101758 RM
543-3333
2.ROSALIE NILLASCA 172440 G5P4;Cephalic in 8-01-18 MRS. JEANY A. 0027164
Laguna Medical Center AMBROCIO CLINICAL
Brgy. Mayondon,Los Labor: Multigravida; 10:15 AM 9-22-2020
J. De Leon St. Sta-Cruz 09062101758 INSTRUCTOR
Banos,Laguna 39 5/7 weeks Age of Laguna
Gestation RM
543-3333
3.SHERLYN CRISTAL 176806 G7P6;Cephalic in 11-19-18 MRS. ROSARIO D. 0053439
Laguna Medical Center OARGA CLINICAL
MACE Labor: Multigravida; 2:53 PM J. De Leon St. Sta-Cruz
5-14-2020
39 2/7 weeks Age of 09177097408 INSTRUCTOR
Brgy.Sampalocan,Pagsanja Laguna
Gestation RM
n,Laguna 543-3333
4.JENALYN CUSI 176792 G8P7;Cephalic in 11-20-18 MRS. ROSARIO D. 0053439
Laguna Medical Center OARGA CLINICAL
Brgy. Yukos, Labor: Teen Age 11:47 PM 5-14-2020
J. De Leon St. Sta-Cruz 09177097408 INSTRUCTOR
Nagcarlan,Laguna Pregnancy; 39 3/7 Laguna
weeks Age of RM
543-3333
Gestation
5.ARMIDA I. DOTE 176795 G8P7;Cephalic in 11-20-18 MRS. ROSARIO D. 0053439
Laguna Medical Center OARGA CLINICAL
Brgy.Damayan,Famy,Lagun Labor: Multigravida; 12:00 AM 5-14-2020
J. De Leon St. Sta-Cruz 09177097408 INSTRUCTOR
a 38 5/7 weeks Age of Laguna
Gestation RM
543-3333

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: ____________
SUBSCRIBED AND SWORN To before me this Printed Name:
____________________ at _____________________Affiant Affix Designation: o
exhibiting to me his/her Residence Certificate No. _______________ Documentary Stamp
License Number: Expiry Date:
issued at ________________________ on ___________________. (to be posted on the last page)