INFORMATION SHEET

TRAINER/PRECEPTORS TRAINING

Date of Training
Application for ( ) Preceptor

( ) Trainer

Nae: / /
(Last Name) (First Name) (Middle Initial)

Base Hospital: Contact No.

Address:

Current Position: Contact No.

ATTENDANCE TO 3DAY Basic IV Training

Where: When:
(Hospital /Institution) (mm/dd/yyyy)

Trainer:

IV Card No: Valid Until:

Requirements to be submitted:

1. Certificate of Employment
2. Photocopy of PRC License (current)
3. 2pcs. 2x2 ID Pictures (light green background)
4. 500.00 Processing fee

NOTE: REGISTER Nurses who have occupied or are currently in administrative managerial positions in government or
private health care facilities are qualified to be members and Trainer/Preceptor of the Association.
 MEMBERSHIP APPLICATION FORM
2X2 picture
White
( ) New Member
Background
( ) Renewal
( ) Life Member

Name:
Last Name First Name Middle Name

Membership ID no. PRC Card no. Valid until

IV Card no. Date Expired

Base Hospital/Institution

Address: Tel no.

Current Position

Residence Address:

Tel no./Cellphone no.

Beneficiary Relationship

Address Tel no/Cel no.

Requirements to be submitted:

1. Old/Previous membership card (For old member)

1.1 Certificate of Employment (For new member)
2. Photocopy of PRC license
3. 2pcs (2X2) recent pictures (white background)
4. P500.00 processing fee

Note: Registered Nurse who had occupied or are currently occupying administrative managerial
positions in government or private health care facilities are qualified to be members of the
Association
Name:
(Last Name) (First Name) (Middle Name)

Base Hospital: Contact No:

Address:

Current Position: Contact No:

PRC License No. Valid Until:

IV Card No: Valid Until:

Two (2) participants of this 3 day Basic IV Training Program were followed up individually by the undersigned.
Attested as signed by the IV Preceptors and National IV Trainer

Date of Training

Procedural Table I
a
b
c
d

Procedural Table II

Procedural Table III

a
b
c
d

Procedural Table IV
a
b
c

Procedural Table V
(One-on-One)

a
b
c

Form P3 s 2010

Signature over Printed Name

ANSAP NATIONAL TRAINER
 Form P5 s 2010

PRECEPTORS’ TRAINING
Financial Guidelines
(c/o ANSAP National IV Trainer)

Name of Hospital offering this 3rd day Training

Date of Training

INCOME:
Registration fee P2,000 x no. of Participants

Registration fee inclusive of the following:

- ANSAP Membership fee
- Hand-outs
- Certificates of Attendance
- Conduction fee
- Module fee
- Honorarium of the Speaker

Expenses C/o Host Hospital

- Board and Lodging, Transportation of ANSAP National IV Trainer
- Venue
- Meals and snacks of participants and ANSAP National IV Trainer

Reports to be submitted to the ANSAP National IV Trainer:

1. Financial Report with proceeds of the training
2. Attendance list
3. Information Sheet
4. Follow-up Sheet
5. Summary of Evaluation Tool

Submitted by:

(Signature over printed name)

Chief Nurse/IV Trainer
 Association of Nursing Service Administrators
of the Philippines, Inc. (ANSAP)

PRECEPTORS’ EVALUATION SHEET

One-day Training Course

Instructions: Please check the item that best describes your opinion of this training Course
(1) Outstanding (2) Very Good (3) Good (4) Fair/Needs improvement

NAME OF NATIONAL IV TRAINER:

A. OBJECTIVE 1 2 3 4 E. TECHNICAL SUPPORT 1 2 3 4

-Relevant to present -Venue
nursing practice
B. COURSE CONTENT -Hand-outs-
-Topics relevant to
nursing practice
-Adequate content -Equipment/ Audio-visual
-Applicable -Length of course
C. RESOURCE SPEAKER
-Clear discussion -Food
-Mastery of Subject F. OBSERVATION/WORKSHOP

-Audience Impact -Objectives met

-Audience participation -Degree of individual
D. KNOWLEDGE OF
PARTICIPANTS
-Before the course -Participation in group
-After the course -Time allotted to workshop
-Can apply new -Presentation
Knowledge
-Technique, skills to job G. OVER-ALL RATING
OF THE TRAINING COURSE

COMMENTS AND SUGGESTIONS: