IVT FORM 09 s 09

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.: __________________________
Date of I V Training Program Attended: ______ Venue: _______________________________

I. Initiating/ Maintaining Peripheral IV Infusions

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




II. Administering Intravenous Drugs

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




III. Administering and Maintaining Blood and Blood Components

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



Submi tted by: ____________________Date Submi tted: __________Recei ved by: __________________Approved by: _______________________
(Si gnature over Pri nted Name) Di rector of Nursi ng Servi ce
(Si gnature over Pri nted Name)