3+3+2 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse: ____________________________________________ PRC No.

Name of Hospital offering I V Training: __________________________________ Provider No.: __________________________

Venue: _______________________________
Date of I V Training Program Attended:

I. Initiating/ Maintaining Peripheral IV Infusions

Patient Kind of Type of Signature over Printed name of License No.
Name of Patient Age Date Time Site Dose Rate
No. Infusion Cannula Certified Trainer/Preceptor/M.D., RN

II. Administering Intravenous Drugs

Patient Kind of Type of Signature over Printed name of License No.

Name of Patient Age Date Time Site Dose Rate
No. Infusion Cannula Certified Trainer/Preceptor/M.D., RN

III. Administering and Maintaining Blood and Blood Components

Patient Name of Patient Age Date Time Kind of Site Type of Dose Rat Signature over Printed name of License No.
No. Infusion Cannula e Certified Trainer/Preceptor/M.D.,
RN
Submitted by: ______________________ Date Submitted: ________________ Received by: __________________ Approved by: _____________________
(Signature over Printed Name) Director
of Nursing Service
(Signatur
e over Printed Name)