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: __________________________________ Provi der 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. Submitted by:____________________Date Submitted:__________Received by:__________ ________Approved by: _______________________ (Signature over Printed Name) Director of Nursing Service (Signature over Printed Name)

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