3+3+1 ACCOMPLISHED REQUIREMENTS of 3- DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES Name of Registered Nurse: Queennie

Marel D. Ramos Name of Hospital offering IV Training: Mercy Community Hospital, Inc. Date of IV Training Program Attended: July 29 -31, 2013 l. Initiating / Maintaining Peripheral IV infusions Patient No. 51641-09 106227-13 105396-13 Name of Patient Camingawan, Segundo Cuizon, Francisco Mendoza, Romarico Age 65 y.o. 82 y.o. 61 y.o. Date August 8,2013 August 8, 2013 August 8, 2013 Time 9:20 AM 11:00AM 01:45 PM Kind of Infusion D5NSS D5NSS D5LR Site Right Metacarpal vein Left Cephalic Vein Right Cephalic Vein Type of Cannula ONC Gauge 18 ONC Gauge 18 ONC Gauge 18 Dose 1 Liter 1 Liter 1 Liter Rate 20 gtts/min Ralf S.Grande, RN KVO Ralf S.Grande, RN 30 gtts/min Ralf S.Grande, RN Signature over Printed name of Certified Trainer /Preceptor / MD, RN License No. Card Number : 09-05367 Expiry Date: Dec.21,2015 Card Number : 09-05367 Expiry Date: Dec.21,2015 Card Number : 09-05367 Expiry Date: Dec.21,2015 PRC Number On Process Provider NO.: 212 Venue: Wellspring Auditorium

ll. Administering Intravenous Drugs Patient No. 103289-13 100811-13 42642-08 Name of Patient Dasmarias, Jacob Arciga, Lucila Manos, Pedrito Age 60 y.o. 57 y.o. 68 y.o. Date August 8, 2013 August 8, 2013 August 8,2013 Time 2:50 PM 01:50 PM 12:30 PM Drugs Incorporated MS2 Cyclophosphamide Zoledronic Acid Dose 20 mg 40mg/kg 4 mg Diagnosis PUD & Cholelithiasis Ralf S.Grande, RN Breast Cancer Ralf S.Grande, RN Myxoid Liposarcoma Ralf S.Grande, RN Signature over Printed name of Certified Trainer / Preceptor / MD, RN License No. Card Number : 09-05367 Expiry Date: Dec.21,2015 Card Number : 09-05367 Expiry Date: Dec.21,2015 Card Number : 09-05367 Expiry Date: Dec.21,2015

lll. Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION) Volume/Blood Type of Signature over Printed Patient No. Name of Patient Age Date Time Type/Components/Rate IV Insertion Cannula Diagnosis name of Certified Trainer / Preceptor / MD, RN 42642-08 Manos, Pedrito 68 y.o. August 3:20 PM 200ml/Blood Type O/ Right Cephalic ONC Myxoid 8,2013 Packed RBC/15 gtts/min Vein Gauge 18 Liposarcoma Ralf S.Grande, RN

License No. Card Number : 09-05367 Expiry Date: Dec.21,2015

Submitted by: Queennie Marel D. Ramos, RN

(Signature over Printed Name)

Date submitted: August 12, 2013

Received by: _____________________

Approved by: Sr. Francisca L. Margate, RSM, RN, MAN

Director of Nursing Services (Signature over Printed Name)