IV Therapy Annual Report

KANSAS STATE BOARD OF NURSING

LANDON STATE OFFICE BUILDING

900 SW JACKSON, SUITE 1051

TOPEKA, KS 66612-1230

IV Therapy Annual Report

Name of Provider
Provider Number
IV Provider Number
Address of Provider

Telephone
E-Mail Address
IV Course Coordinator
Reporting Year: Enter just the Year

Did you provide IV Therapy Courses this reporting year?

YES

If you answered YES please fill in the Information below, otherwise select NO and click submit.

Format for the Date of Course will need to be in the format of mm-dd-yyy: i.e. 03-24-2014.

Date of Course	RN's Enrolled	LPN's Enrolled	LPN's Withdrew	LPN's Failed	LPN's Certified

Attestation
I realize that this application is a legal document and by pressing the Submit button you are declaring under penalty of perjury under the laws of the State of Kansas that the information I have provided is true and correct to the best of my knowledge.
If all the above information is correct please press the Submit button .
Otherwise please go back and correct any information that is necessary.