PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF MIDWIFERY
RECORD OF ACTUAL DELIVERIES HANDLED
Please Check if Applicant is:
√ Graduate Midwife Registered Nurse

Name of Applicant: BOSQUE, CHARLOTE KAYE PITALGO School: SCHOLA DE SAN JOSE, INC (Formerly: Provincial Technical Institute for Southern Mindanao)

Case Date & Time Full Name, Address of Check Supervised by:
Name and Compplete Diagnosis (Gravida __ Para __ ) No. Performed Facility & Contact if Home Printed Name & Position/ License No./
Signature
Number Delivery Contact No. Designation Exp. Date
1. Stephany, 28 years old, Gravida 2 Para 2 (2002). Pregnancy Uterine 39 weeks Heramil Hospital
and 4 days Age of Gestation, cephalic in labor, delivered Normal Spontaneous 19-124 4/26/2019 Polomolok, South Cotabato DAISY A. CRUZ, RM Clinical 0060909
Delivery to a live Baby Girl with an Apgar Score of 9, Birth Weight 3200 grams. 02:20 P.M (083) 500-9247 09293758345 Instructor 03/19/2022
 Case Date & Time Full Name, Address of Check Supervised by:
Name and Compplete Diagnosis (Gravida __ Para __ ) No. Performed Facility & Contact if Home Printed Name & Position/ License No./
Signature
Number Delivery Contact No. Designation Exp. Date
11. Mediatrix, 36 years old, Gravida 4 Para 4 (4004). Pregnancy Uterine 39 weeks Heramil Hospital
and 3 days Age of Gestation, cephalic in labor, delivered Normal Spontaneous 19-154 5/26/2019 Polomolok, South Cotabato DAISY A. CRUZ, RM Clinical 0060909
Delivery to a live Baby Girl with an Apgar Score of 8, Birth Weight 3000 grams. 10:50 P.M (083) 500-9247 09293758345 Instructor 03/19/2022

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 Polomolok, South Cotabato on _____________.
CERTIFIED CORRECT:
______________________________ Affix
Administering Officer or Notary Public Documentary Stamp Signature: ______________ Date: _______________
Printed Name: WILMA T. HERAMIL, MD
Designation: Principal/Chairman Health Services Education Unit
License No.: 0078733 Expiry Date: 11/17/2021
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
RECORD OF ACTUAL INTERNAL EXAMINATION
Please Check if Applicant is:

√ Graduate Midwife Registered Nurse

Name of Applicant: BOSQUE, CHARLOTE KAYE PITALGO School: SCHOLA DE SAN JOSE, INC. (Formerly: Provincial Technical Institute for Southern Mindanao)
Case Date & Time Full Name, Address of Check Supervised by:
Name and Compplete Diagnosis (Gravida __ Para __ ) No. Performed Facility & Contact if Home Printed Name & Position/ License No./
Signature
Number Delivery Contact No. Designation Exp. Date
1. Stephany, 28 years old, Gravida 2 Para 1 (1001). Pregnancy Uterine 39 weeks and 4 days Heramil Hospital
Age of Gestation, cephalic in labor, 8 cm dilated, 80 % effaced, Intact Bag of Water, 19-124 4/26/2019 Polomolok, South Cotabato DAISY A. CRUZ, RM Clinical 0060909
station +1. 12:10 P.M (083) 500-9247 09293758345 Instructor 03/19/2022
 Case Date & Time Full Name, Address of Check Supervised by:
Name and Compplete Diagnosis (Gravida __ Para __ ) No. Performed Facility & Contact if Home Printed Name & Position/ License No./
Signature
Number Delivery Contact No. Designation Exp. Date
11. Mediatrix, 36 years old, Gravida 4 Para 3 (3003). Pregnancy Uterine 39 weeks and Heramil Hospital
3 days Age of Gestation, cephalic in labor, 9 cm dilated, 90 % effaced, Ruptured Bag 19-154 5/26/2019 Polomolok, South Cotabato DAISY A. CRUZ, RM Clinical 0060909
of Water, amniotic fluid clear in color, station +2. 09:45 P.M (083) 500-9247 09293758345 Instructor 03/19/2022

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 Polomolok, South Cotabato on _____________.
CERTIFIED CORRECT:
______________________________ Affix
Administering Officer or Notary Public Documentary Stamp Signature: ______________ Date: _______________
Printed Name: WILMA T. HERAMIL, MD
Designation: Principal/Chairman Health Services Education Unit
License No.: 0078733 Expiry Date: 11/17/2021
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
RECORD OF ACTUAL INTRAVENOUS INSERTION
Please Check if Applicant is:

√ Graduate Midwife Registered Nurse

Name of Applicant: BOSQUE, CHARLOTE KAYE PITALGO School: SCHOLA DE SAN JOSE, INC. (Formerly: Provincial Technical Institute for Southern Mindanao)

Date & Time Full Name, Address of Check Supervised by:

Name and Compplete Diagnosis (Gravida __ Para __ ) Case No. Performed Facility & Contact Number if Home Printed Name & Position/ License No./
Signature
Delivery Contact No. Designation Exp. Date
1. Jellie, 25 years old, Gravida 1 Para 0. Pregnancy Uterine 38 weeks and 1 day Age of Gestation,
cephalic in beginning labor. Heramil Hospital
Jellie, 25 years old, Gravida 1 Para 1 (1001). Pregnancy Uterine 38 weeks and 1 day Age of 19-127 4/28/2019 Polomolok, South Cotabato DAISY A. CRUZ, RM Clinical 0060909
Gestation, cephalic normal spontaneous delivery to an alive term Baby Girl, Birth Weight 3300 grams, 6:55 A.M. (083) 500-9247 09293758345 Instructor 3/19/2022
Premature Rupture of Membrane x 3 hours.

NOTE: 1.) For Graduate Midwives: Supervision must be by qualified Faculty / Clinical Instructor.
2. Registered Midwives / Clinical Instructors who supervise the student midwives affix their signatures in this form must present a certificate of CERTIFIED CORRECT:
Training of Suturing of Perineal Lacerations to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.
Signature: ______________ Date: _______________
SUBSCRIBED AND SWORN TO before me this ___________________ at ____________________ Affiant exhibiting to me his/her Residence Printed Name: WILMA T. HERAMIL, MD
Certificate No. issued at Polomolok, South Cotabato on _____________. Designation: Principal/Chairman Health Services Education Unit
______________________________ License No.: 0078733 Expiry Date: 11/17/2021
Administering Officer or Notary Public
 PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
RECORD OF ACTUAL SUTURING OF PERINEAL LACERATIONS

Please Check if Applicant is:

√ Graduate Midwife Registered Nurse

Name of Applicant: BOSQUE,CHARLOTE KAYE PITALGO School: SCHOLA DE SAN JOSE (Formerly: Provincial Technical Institute for Southern Mindanao)

Case Date & Time Full Name, Address of Check Supervised by:
Name and Compplete Diagnosis (Gravida __ Para __ ) No. Performed Facility & Contact if Home Printed Name & Position/ Signature License No./
Number Delivery Contact No. Designation Exp. Date
1. Stephany, 28 years old, Gravida 2 Para 2 (2002). Pregnancy Uterine 39 weeks and 4 days Age of Heramil Hospital
Gestation, cephalic presentation, delivered Normal Spontaneous Delivery to a live term Baby girl 19-124 4/26/2019 Polomolok, South Cotabato DAISY A. CRUZ, RM Clinical 0060909
at 2:20pm, with an Apgar Score of 9, Birth Weight 3200 grams. Placenta delivered at 2:25pm, 02:41 P.M (083) 500-9247 09293758345 Instructor 03/19/2022
Suture started 2:27pm - suture ended at 2:41pm. Second degree of perineal laceration repaired.

NOTE: 1.) For Graduate Midwives: Supervision must be by qualified Faculty / Clinical Instructor.
2. Registered Midwives / Clinical Instructors who supervise the student midwives affix their signatures in this form must present a certificate of
Training of Perineal Lacerations to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.

SUBSCRIBED AND SWORN TO before me this ___________________ at ____________________ Affiant exhibiting to me his/her Residence CERTIFIED CORRECT:
Certificate No. issued at Polomolok, South Cotabato on _____________.
Signature: ______________ Date: _______________
_______________________________ Printed Name: WILMA T. HERAMIL, MD
Administering Officer or Notary Public Designation: Principal/Chairman Health Services Education Unit
License No.: 0078733 Expiry Date: 11/17/2021