COURSE EVALUATION TOOL

Course Title:
Institution :

Instruction: Please check (√) the item below that best describes your opinion/[erce[tion of the cours

1 - Poor 3 - Good
2 - Fair 4 - Outstanding

CRITERIA
A. Obejectives
- Relevant to nursing practice

B. Course Content
-Topics relevant to I.V. Therapy
- Adequacy of course content
- Applicable to current I.V. Theapy practice
C. Resource Speaker
- Discusses the subject matter clearly
-Mastery of the subject matter
-Audience impact and audience participation
D. Knowledge of participants
- Knowledge before attending the course offering
- Knowledge after attending the course offering
- Can apply new knowledge, technique/skills to present job
E. Technical support/ assistance
- Training site / Venue
- Hand-outs
- Audio-visual materials and equipment
F. Practicum
- Objectives met
- Systemic conduction of return demonstration
- Time allotment

Comments on Attitude, Attendance and Participation of Participants:

Other Suggestions:

Signature of Participant/ over Printed Name :

Participant's Hospital Address :
 Date:

opinion/[erce[tion of the course offering.

- Outstanding

1 2 3 4 REMARKS

ob
 Evaluation Form

TOPIC: 1
A. Name of Mastery of Subject
IV Trainer Clarity
Preceptor
Speaker Use of Handouts and Visual Aids
Relevant to Experience/ Examples
Ability to establish Rapport
Time alloted

TOPIC: 1
A. Name of Mastery of Subject
IV Trainer Clarity
Preceptor
Use of Handouts and Visual Aids
Speaker
Relevant to Experience/ Examples
Ability to establish Rapport
Time alloted

TOPIC: 1
A. Name of Mastery of Subject
IV Trainer Clarity
Preceptor
Use of Handouts and Visual Aids
Speaker
Relevant to Experience/ Examples
Ability to establish Rapport
Time alloted

Other Comments/ Remarks:

What suggestion/s do you have to improve future seminars:

NOTE: Submission of this Evaluation Form duly accomplished to the IV Trainer/ IV Prog
issuance of the certificate of attendance.
 2 3 4 5

2 3 4 5

2 3 4 5

to the IV Trainer/ IV Program Coordinator for the

 IV THERAP

Name of Hospital

Title of Program:
Date when Program was approved:
Date when Program was offered:

Name of Registered Nurse

HOSPITAL where R.N. is connected
(Please Print)

Family Name, First Name, Middle

Initial

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19
 IV THERAPY ATTENDANCE SHEET FORMAT

Address
Venue:
Address:

3 - Days I.V. Therapy Trainin

N. is connected PRC License DAY 1 DATE: DAY 2 DATE:

Number Date of Expiry A.M. P.M. A.M.

Trainer's Signature over Printed Name/ I.V. Car
 No. Cert. of Reg./ Expiry

ys I.V. Therapy Training

AY 2 DATE: DAY 3 DATE:

P.M. A.M. P.M.

er Printed Name/ I.V. Card No./Expiry Date
 IV

Name of Hospital

Title of Program:
Date when Program was approved:
Date when Program was offered:

PRINTED NAME OF PARTICIPANTS DIDACTIC 50%

I
RECEIVED BY:
Representative, ANSAP, Inc.
NOTED BY:
I.V. Program Director, ANSAP
 IV THERAPY GRADING SHEET FORMAT

of Hospital No. Cert. of Reg./ Expiry

Address
Venue:
Address:

PRACTICUM 50% PROCEDURE

I II III IV V TOTAL GRADE

SUBMITTED BY:

APPROVED BY:
 FINAL GRADE REMARKS

TOTAL GRADE
Trainer's Signature over Printed Name

Chief Nurse
 IV THERAPY

Name of Hospital

Date when Program was approved:

Name of Registered Nurse Name of HOSPITAL where R.N. will

(Please Print) complete their cases

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 IV THERAPY ATTENDANCE SHEET FORMAT

Address

Date when Program was offered:

where R.N. will Name of Trainer/ Preceptor assigned as

JAN FEB MAR APR
eir cases witnesses (with card no. & expiry date)
 No. Cert. of Reg./ Expiry

MAY JUN JUL AUG SEP OCT NOV DEC

Name of Registered Nurse
Name of Hospital offering IV Training
Date of IV Training Program Attended

I. Initiating/ Maintaining Peripheral IV Infusions

Patient No. Name of Patient Age Date

II. Administering Intravenous Drugs

Patient No. Name of Patient Age Date

III. Administering and Maintaining Blood and Blood Components

Patient No. Name of Patient Age Date

Submitted by: Date Submited :
Signature over Printed Name
 3+3+2 ACCOMPLISHED REQUIREMENTS of
3 - DAY BASIC THERAPY TRAINING PROGRAM FOR NURSES

Time Kind of Infusion Site

Time Drugs Incorporated Dose

Blood Components

Time Volume/ Blood Type / Components/ Rate IV Insertion

ubmited : Received by :
S of
OR NURSES

PRC Number
Provider No.
Venue

Type of Signature over Printed name of

Dose Rate
Cannula Certified Trainer/ Preceptor

Signature over Printed name of

Diagnosis
Certified Trainer/ Preceptor

Type of Signature over Printed name of

Diagnosis
Cannula Certified Trainer/ Preceptor
Approved by:
Director of Nursing Services
Signature over Printed Name
License No.

License No.

License No.
Services
ed Name