EMILIO AGUINALDO COLLEGE

School of Midwifery
Bachelor of Science in Midwifery

MAJOR CASES
OB-GYNE
NAME: ___________________________________

License number Signature of

Date Name of Patient and Complete
Case Number & date of qualified Clinical
Performed Address Diagnosis
expiration Instructor

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 : ____________________
Documentary Stamp Printed Name : ____________________
(To be posted on the last page) Designation : ____________________
Lic. No. : ____________________
 EMILIO AGUINALDO COLLEGE
School of Midwifery
Bachelor of Science in Midwifery

MINOR CASES
OB-GYNE
NAME: ___________________________________

License number Signature of

Date Name of Patient and Complete
Case Number & date of qualified Clinical
Performed Address Diagnosis
expiration Instructor

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 : ____________________
Documentary Stamp Printed Name : ____________________
(To be posted on the last page) Designation : ____________________
Lic. No. : ____________________
 EMILIO AGUINALDO COLLEGE
School of Midwifery
Bachelor of Science in Midwifery

INTERNAL EXAMINATION
(Cases)

CLINICAL
NO. DATE PATIENT’S NAME AGE CLINICAL FINDINGS
INSTRUCTOR
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
 EMILIO AGUINALDO COLLEGE
School of Midwifery
Bachelor of Science in Midwifery

INTRAVENOUS INSERTION
(Cases)

CLINICAL
NO. DATE PATIENT’S NAME AGE CLINICAL FINDINGS
INSTRUCTOR
1.
2.
3.
4.
5.
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Deliveries Handled
Please Check:
Graduate Midwife Registered Nurse
Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila
Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: _______ Date: ________
Administering Officer or Notary Public Printed Name: ________________
Designation: __________________
Lic.No.: _____Expiry Date: ______
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Internal Examination
Please Check:
Graduate Midwife Registered Nurse
Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila
Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: _______ Date: ________
Administering Officer or Notary Public Printed Name: ________________
Designation: __________________
Lic.No.: _____Expiry Date: ______
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Suturing of Perineal Laceration

Please Check:
Graduate Midwife Registered Nurse
Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila

Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: _______ Date: ________
Administering Officer or Notary Public Printed Name: ________________
Designation: __________________
Lic.No.: _____Expiry Date: ______
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
Record of Actual Intravenous Insertion

Please Check:
Graduate Midwife Registered Nurse
Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila

Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: _______ Date: ________
Administering Officer or Notary Public Printed Name: ________________
Designation: __________________
Lic.No.: _____Expiry Date: ______
 EMILIO AGUINALDO COLLEGE
Manila
SCHOOL OF MIDWIFERY
Bachelor of Science in Midwifery

Record of Major Cases Handled

Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila

Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: ____________ Date: ____________
Administering Officer or Notary Public Printed Name: __________________________
Designation: ___________________________
Lic.No.: __________ Expiry Date: _________
 EMILIO AGUINALDO COLLEGE
Manila
SCHOOL OF MIDWIFERY
Bachelor of Science in Midwifery

Record of Minor Cases Handled

Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila

Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: ____________ Date: ____________
Administering Officer or Notary Public Printed Name: __________________________
Designation: ___________________________
Lic.No.: __________ Expiry Date: _________
 EMILIO AGUINALDO COLLEGE
Manila
SCHOOL OF MIDWIFERY
Bachelor of Science in Midwifery

Record of Actual Suturing of Perineal Laceration

Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila

Name and Case Complete Date & Full Name, Address of Check Supervised
Address No. Diagnosis Time Facility & Contact If Home Printed Name & Position/ Signature Licens No./
of patient (Gravid_Para_) Performed Number Del Contact No. Designation Exp. Date

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:
___________________________________ Signature: ____________ Date: ____________
Administering Officer or Notary Public Printed Name: __________________________
Designation: ___________________________
Lic.No.: __________ Expiry Date: _________
 EMILIO AGUINALDO COLLEGE
Manila
SCHOOL OF MIDWIFERY
Bachelor of Science in Midwifery

Record of Actual Intravenous Insertion

Name of Applicant:_________________________ School: Emilio Aguinaldo College – Manila

Name and Case Complete Date & Full Name, Address of Supervised
Address No. Diagnosis Time Facility & Contact Number Printed Name & Position/ Signature Licens No./ Exp.
of patient (Gravid_Para_) Performed Contact No. Designation Date

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:
___________________________________ Signature: ____________ Date: ____________
Administering Officer or Notary Public Printed Name: __________________________
Designation: ___________________________
Lic.No.: __________ Expiry Date: _________