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I V THERAPY ACCOMPLISHED REQUIREMENTS

Venue: ____
Name of Hospital Offering I V Training Province/Region:
_____ ANSAP Chapter: __________________
Address

Ac c om p lis he d Re q uir em e nt s of:


Name of Registered Nurse: PRC No. ________ Expiry Date: _____
Date of I V Training Program Attended: I V Requirements: _6 + 6 + 2_
Registration No. of Institution Offering the I V Training Program: __________

Date / Time / Site of I V Insertion Signature of Witness


Kind of IV
Name of Patient Age Type of Cannula / Dose / Rate / M.D./I V Trained
Infusion given
Drug Incorporation present Preceptor
I. Initiating & Maintaining Peripheral I V Infusions
1.
2.
3.
4.
5.
6.
Drug Incorporated/
II. Administering I V Drugs Date / Time / Diagnosis
Dose
1.
2.
3.
4.
5.
6.
III. Administering & Maintaining Blood & Blood Components
Blood Type / Date / Time / Site of I V Insertions
Volume / Components Type of Cannula / Rate
1.
2.
This is to certify that I had successfully performed the above requirements, as countersigned by m y witnesses.

Received by: ____________________________________________ Submitted by: _____________________________________________


ANSAP Signature over Printed Name of RN
I V Therapy Certification Card No. _____________________________ Approved by: ______________________________________________
Director, Nursing Service
Issued by: ____________________ Date: ______________________ Date Submitted: ____________________________________________
Note: To be submitted in duplicate to the ANSAP office within six (6) Months after Training.