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