I V THERAPY ACCOMPLISHED REQUIREMENTS

Venue:
Name of Hospital Offering I V Training Province/Region:
ANSAP Chapter:
Address

Accomplished Requirements of:

Name of Registered Nurse: PRC No. Expiry Date:

Date of I V Training Program Attended: 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 Infusions
1.
2.
3.
4.
5.
6.
Drug Incorporated/
II. Administering I V Drugs Date / Time / Diagnosis
Dose
1.
2.
3.
4.
5.
6.
III. Administering & Maintaining Blood & Blood Components
Blood Type / Date / Time / Site of I V Insertions
Volume / Components Type of Cannula / Rate
1.
2.

Th is is to ce rt if y t ha t I h ad su cce ssf u lly pe rf o rm ed t he ab o ve re qu irem e nt s, as cou n te rsi gn ed b y m y wit n e sse s.

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.