3+3+2 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse: _Jillianne M. Bertiz_____________________________________________________ PRC Number: __0594229__________________________________________
Name of Hospital offering IV Training: _Queen Mary Help of Christians Hospital__________________________ Provider No. : __218______________________________________________
Date of IV Training Program Attended _February 19-21, 20110_________________________________________ Venue: _DMDJ Audi Queen Mary Help of Christians Educational Center___

I. Initiating/ Maintaining Peripheral IV Infusions

Signature over Printed Name
Patient Name of Patient Age Date Time Kind of Infusion Site Type of Cannula Dose Rate of Certified Trainer/ License
No. Preceptor No.

II. Administering Intravenous Drugs

Signature over Printed Name
Patient Name of Patient Age Date Time Drugs incorporated Dose Diagnosis of Certified Trainer/ License
No. Preceptor No.

III. Administering and Maintaining Blood and Blood Components

Signature over Printed Name
Patient Name of Patient Age Date Time Volume/ Blood Type/ Components/ IV Insertion Type of Diagnosis of Certified Trainer/ License
No. Rate Cannula Preceptor No.

Submitted by: __Jillianne M. Bertiz____ Date Submitted:________________________ Received by: ________________________________________ Approved by: _________________________________
(Signature over Printed Name) Director of Nursing Service
(Signature over Printed Name)