IVT FORM 09 s 09

3+3+2 ACCOMPLISHED REQUIREMENTS of 3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse: ____________________________________________ Name of Hospital offering I V Training: __________________________________ Date of I V Training Program Attended: ______ I. Initiating/ Maintaining Peripheral IV Infusions
Patient No. Kind of Infusion Type of Cannula Signature over Printed name of Certified Trainer/Preceptor/M.D., RN

PRC No. Provider No.: __________________________ Venue: _______________________________

Name of Patient

Age

Date

Time

Site

Dose

Rate

License No.

II. Administering Intravenous Drugs

Patient No. Kind of Infusion Type of Cannula Signature over Printed name of Certified Trainer/Preceptor/M.D., RN

Name of Patient

Age

Date

Time

Site

Dose

Rate

License No.

III. Administering and Maintaining Blood and Blood Components

Patient No. Kind of Infusion Type of Cannula Signature over Printed name of Certified Trainer/Preceptor/M.D., RN

Name of Patient

Age

Date

Time

Site

Dose

Rate

License No.

Submitted by:____________________Date Submitted:__________Received by:__________________Approved by: _______________________

(Signature over Printed Name) Dire ctor of Nursing Se rvice (Signature over Printed Name)