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: __________________________________ Provider No.: __________________________
Date of I V Training Program Attended: ______ Venue: _______________________________

I. Initiating/ Maintaining Peripheral IV Infusions

Patient Kind of Type of Signature over Printed name of

Name of Patient Age Date Time Site Dose Rate License No.
No. Infusion Cannula Certified Trainer/Preceptor/M.D., RN

II. Administering Intravenous Drugs

Patient Kind of Type of Signature over Printed name of

Name of Patient Age Date Time Site Dose Rate License No.
No. Infusion Cannula Certified Trainer/Preceptor/M.D., RN

III. Administering and Maintaining Blood and Blood Components

Patient Kind of Type of Signature over Printed name of

Name of Patient Age Date Time Site Dose Rate License No.
No. Infusion Cannula Certified Trainer/Preceptor/M.D., RN

Submitted by:____________________Date Submitted:__________Received by:__________________Approved by: _______________________

(Signature over Printed Name) Dire ctor of Nursing Se rvice
(Signature over Printed Name)