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 Infusion 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.,R.N. License No PRC No:_____________________________ Provider No:_________________________ Venue: _____________________________

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.,R.N. 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.,R.N. License No

Submitted By:________________________________ Date Submitted:______________ Signature Over Printed Name

Received By:_____________________

Approved By: _____________________________ Director of Nursing Service