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

of Hospital offering IV Training Date of IV Training Program Attended I. Initiating/Maintaining Peripheral IV Infusions Patient No. Name of Patient Age Date Time Kind of Infusion Site
Type of Cannula

PRC Number Provider No. Venue

RUN Bldg., Pawa, Tabaco City

Dose

Rate

II. Administering Intravenous Drugs Patient No. Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis

III. Administering and Maintaining Blood and Blood Components Patient No. Name of Patient Age Date Time Volume/Blood Type/ Components/Rate IV Insertion
Type of Cannula

Diagnosis

Submitted by: (Signature over Printed Name)

Date submitted:

Received by:

Approved by:

Pawa, Tabaco City

Signature over Printed Name of Certified Trainer/Preceptor

License No.

Signature over Printed Name of Certified Trainer/Preceptor

License No.

Signature over Printed Name of Certified Trainer/Preceptor

License No.

Director of Nursing Services (Signature over Printed Name)