3 + 3 +2 ACCOMPLISHED REQUIREMENTS of

3 - DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse : ________________________________________________ PRC Number : _______________________________________

Name of Hospital offering IV Training : MEYCAUAYAN DOCTORS HOSPITAL Provider Number : 217
Date of IV Training Program Attended : APRIL 1, 2 & 3, 2011 Venue : IS FUNCTION HALL, MEYCAUAYAN BULACAN

I. Initiating / Maintaining Peripheral IV Infusions

Patient Types of
Name of Patient Age Date Time Kind of Infusion Site Dose Rate
No. Cannula

II Administering Intravenous Drugs

Patient Drugs
Name of Patient Age Date Time Dose Diagnosis
No. Incorporated

III Administering and Maintaining Blood and Blood Components

Patient Volume/Blood IV Type of
Name of Patient Age Date Time Diagnosis
No. Type/Components/Rate Insertion Cannula

Submitted by: ________________________ Date Submitted: ______________________ Received by: ________________________ Approved by:
Signature and
Signatured tFad
Over Printed Name
 IVT FORM 09 s 09

_______________________________

HALL, MEYCAUAYAN BULACAN

Signatured over printed name of

License No.
Certified Trainer/Preceptor

Signatured over printed name of

License No.
Certified Trainer/Preceptor

Signatured over printed name of

License No.
Certified Trainer/Preceptor

pproved by: MARICRIS C. NONO, RN, MAN

Director of Nursing Service