3 3

Name of Registered Nurse: Name of Hospital Offering IVT Training: Date of IV Training Program Attended:

+ 3 + 1 ACCOMPLISHED REQUIREMENTS of DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
PRC Number: Provider Number: Venue:

I.
Patie nt No.

Initiating / Maintaining Peripheral IV Infusion

Name of Patient Age Dat e Tim e Kind of Infusion Site Type of Cann ula Dos e Rat e Signature over Printed Name Of Certified Trainer / Preceptor / M.D., R.N. PRC licens e No.

II.
Patie nt No.

Administering Intravenous Drugs

Name of Patient Age Dat e Tim e Drugs Incorporated Site Type of Cann ula Dos e Rat e Signature over Printed Name Of Certified Trainer / Preceptor / M.D., R.N. PRC licens e No.

III.
Patie nt No.

Administering and Maintaining Blood and Blood Components

Name of Patient Age Dat e Tim e Volume / Blood Type / Component Site Type of Cann ula Dos e Rat e Signature over Printed Name Of Certified Trainer / Preceptor / M.D., R.N. PRC licens e No.

Submitted by: Signature over Printed Name Date Submitted: Received by:

Approved by: Signature over Printed Name