I V THERAPY ACCOMPLISHED REQUIREMENTS

Name of Hospital Offering I V Training Address A c c o m p l i s he d R e qui r e me n t s of : Name of Registered Nurse: Date of I V Training Program Attended: Registration No. of Institution Offering the I V Training Program: Name of Patient Age Kind of IV Infusion given PRC No. Expiry Date: Venue: Province/Region: ANSAP Chapter:

Requirements: 6 + 6 + 2 Date / Time / Site of I V Insertion Type of Cannula / Dose / Rate / Drug Incorporation present Signature of Witness M.D./I V Trained Preceptor

I. Initiating & Maintaining Peripheral I V Infusions 1. 2. 3. 4. 5. 6. II. Administering I V Drugs 1. 2. 3. 4. 5. 6. III. Administering & Maintaining Blood & Blood Components Blood Type / Volume / Components 1. 2. Thi s is to cert ify that I had successfully performed t he above requi rement s, as countersi gned by my wi tnesses. Received by: ____________________________________________ ANSAP I V Therapy Certification Card No. _____________________________ Issued by: ____________________ Date: ______________________ Submitted by: _____________________________________________ Signature over Printed Name of RN Approved by: ______________________________________________ Director, Nursing Service Date Submitted: ____________________________________________ Date / Time / Site of I V Insertions Type of Cannula / Rate Drug Incorporated/ Dose Date / Time / Diagnosis

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