3+3+2 ACCOMPLISHED REQUIREMENTS OF

3- DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse: PRC No. of Participant:

Name of Hospital Offering IV Trainings: Provider No: 017
Date of I.V. Training Program Attended: Venue: Conference Room

I. Initiating & Maintaining Peripheral I.V. Infusion

Kind of Type of Signature of Certified License
Patient No Name of Patient Age Date Time Site Dose Rate
Infusion Cannula Trainer/Preceptor/M.D/R.N No.

II. Administering Intravenous Drugs

Signature of Certified License
Patient No Name of Patient Age Date Time Drug Incorporated Dose Diagnosis
Trainer/Preceptor/M.D/R.N No.

III. Administering & Maintaining Blood & Blood Components

Volume/Blood Type of Signature of Certified License
Patient No Name of Patient Age Date Time I.V. Insertion Diagnosis
Type/Components/Rate Cannula Trainer/Preceptor/M.D/R.N No.

Submitted by:________________________________ Date Submitted: ______________ Received by: _______________ Approved by: ______________________
Director of Nursing Service
(Signature over PrintedName)