3 + 3 + 1 ACCOMPLISHED REQUIREMENTS of 3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse: Name of Hospital Offering IVT Training: Date of IV Training Program Attended: PRC Number: Provider Number: Venue:

I.

Initiating / Maintaining Peripheral IV Infusion

Name of Patient Age Dat e Tim e Kind of Infusion Site Type of Cann ula Dos e Rat e Signature over Printed Name Of Certified Trainer / Preceptor / M.D., R.N. PRC licen se No.

Patie nt No.

II.

Administering Intravenous Drugs

Name of Patient Age Dat e Tim e Drugs Incorporated Site Type of Cann ula Dos e Rat e Signature over Printed Name Of Certified Trainer / Preceptor / M.D., R.N. PRC licen se No.

Patie nt No.

III.

Administering and Maintaining Blood and Blood Components

Name of Patient Age Dat e Tim e Volume / Blood Type / Component Site Type of Cann ula Dos e Rat e Signature over Printed Name Of Certified Trainer / Preceptor / M.D., R.N. PRC licen se No.

Patie nt No.

Submitted by: Signature over Printed Name

Date Submitted:

Received by:

Approved by: Signature over Printed Name