IVT Training Accomplished Requirements Form (3 3 2)

							                                                                                                                                                     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)