Venue: ____

Name of Hospital Offering I V Training Province/Region:

_____ ANSAP Chapter:
Address

A cc om plis he d Re quir e m e nts of:

Name of Registered Nurse: PRC No. ________ Expiry Date:
Date of I V Training Program Attended: I V Requirements: 6 + 6 + 2
Registration No. of Institution Offering the I V Training Program:

Date / Time / Site of I V Insertion Signature of Witness

Kind of IV
Name of Patient Age Type of Cannula / Dose / Rate / M.D./I V Trained
Infusion given
Drug Incorporation present Preceptor
I. Initiating & Maintaining Peripheral I V Insertions
1.
2.
3.
4.
5.
6.
II. Administering I V Drugs Date / Time / Diagnosis
1.
2.
3.
4.
5.
6.
III. Administering and Maintaining Blood & Blood Components
Blood Type / Date / Time / Site of I V Insertions
Volume / Components Type of Cannula / Rate
1.
2.
This is to certify that I had successfully performed the above requirements, as countersigned by my witnesses.

Received by: Submitted by:

ANSAP Signature over Printed Name of RN
I V Therapy Certification Card No. Approved by:
Director, Nursing Service
Issued by: Date: Date Submitted:

Note: To be submitted in duplicate to the ANSAP office within six (6) Months after Training.