DA Form 7595-3-1 Initiate an Intravenous Infusion

DA Form 7595-3-1 - also known as the "Initiate An Intravenous Infusion" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 7595-3-1 - was last revised on March 1, 2014. Download an up-to-date fillable PDF version of the DA 7595-3-1 below or request a copy through the chain of command.

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INITIATE AN INTRAVENOUS INFUSION
For use of this form see TC 8-800; the proponent agency is TRADOC.
III
TABLE:
STP 8-68W13-SM-TG, Tasks: 081-833-0033, Initiate an Intravenous Infusion; Prehospital Trauma Life
REFERENCE:
Support
(PHTLS),
Revised Military Edition.
PRIVACY ACT STATEMENT
10 U.S.C. S 3013 Secretary of the Army; AR 350-1, Army Training Leadership and Development.
AUTHORITY:
S
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT certification
IAW AR 40-68, AR 220-1 and AR 350-1.
ROUTINE USES:
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of the
Army's compilation of system of records notices may apply to this system.
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error in
DISCLOSURE:
processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
The lead Stryker infantry carrier vehicle traveling directly in front of your vehicle has been struck by an improvised explosive device. You determine that you
must establish peripheral intravenous (IV) access to the patients in order to give fluids.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Identified the patient and explained the procedure (if conscious).
b. Selected and inspected the equipment for defects, expiration date and contamination.
c. Prepared the equipment.
d. Selected the infusion site.
e. Donned gloves.
f. Prepared the infusion site.
g. Punctured the vein.
h. Confirmed the puncture.
i. Advanced the catheter over needle.
j. Removed the protective cover from the needle adapter on the tubing; connected the adapter to the catheter or
the needle hub.
k. Released the constricting band.
l. Loosened the flow regulator and adjusted the flow rate.
m. Checked the site for infiltration.
n. Secured the IV site with a transparent dressing.
o. Readjusted flow rate, if needed.
p. Labeled a piece of tape with date/time initiated catheter size, and their initials; secured the tape to the IV
tubing.
q. Removed gloves and disposed of them appropriately.
r. Documented the procedure on the appropriate medical form.
4. Demonstrated Proficiency
Yes
No
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc.
, skill sheets ©2011, this form has neither been prepared nor approved by NREMT. Use is
(NREMT)
restricted to guidelines contained in the Preface to TC 8-800.
Page 1 of 2
Supersedes DA Form 7595-18-R, MAY 2009
DA FORM 7595-3-1, MAR 2014
APD LC v1.00
INITIATE AN INTRAVENOUS INFUSION
For use of this form see TC 8-800; the proponent agency is TRADOC.
III
TABLE:
STP 8-68W13-SM-TG, Tasks: 081-833-0033, Initiate an Intravenous Infusion; Prehospital Trauma Life
REFERENCE:
Support
(PHTLS),
Revised Military Edition.
PRIVACY ACT STATEMENT
10 U.S.C. S 3013 Secretary of the Army; AR 350-1, Army Training Leadership and Development.
AUTHORITY:
S
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT certification
IAW AR 40-68, AR 220-1 and AR 350-1.
ROUTINE USES:
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of the
Army's compilation of system of records notices may apply to this system.
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error in
DISCLOSURE:
processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
The lead Stryker infantry carrier vehicle traveling directly in front of your vehicle has been struck by an improvised explosive device. You determine that you
must establish peripheral intravenous (IV) access to the patients in order to give fluids.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Identified the patient and explained the procedure (if conscious).
b. Selected and inspected the equipment for defects, expiration date and contamination.
c. Prepared the equipment.
d. Selected the infusion site.
e. Donned gloves.
f. Prepared the infusion site.
g. Punctured the vein.
h. Confirmed the puncture.
i. Advanced the catheter over needle.
j. Removed the protective cover from the needle adapter on the tubing; connected the adapter to the catheter or
the needle hub.
k. Released the constricting band.
l. Loosened the flow regulator and adjusted the flow rate.
m. Checked the site for infiltration.
n. Secured the IV site with a transparent dressing.
o. Readjusted flow rate, if needed.
p. Labeled a piece of tape with date/time initiated catheter size, and their initials; secured the tape to the IV
tubing.
q. Removed gloves and disposed of them appropriately.
r. Documented the procedure on the appropriate medical form.
4. Demonstrated Proficiency
Yes
No
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc.
, skill sheets ©2011, this form has neither been prepared nor approved by NREMT. Use is
(NREMT)
restricted to guidelines contained in the Preface to TC 8-800.
Page 1 of 2
Supersedes DA Form 7595-18-R, MAY 2009
DA FORM 7595-3-1, MAR 2014
APD LC v1.00
INITIATE AN INTRAVENOUS INFUSION
Grading Sheet (cont'd)
5. Start Time
6. Stop Time
7. Initial Evaluator
8. Start Time
9. Stop Time
10. Retest Evaluator
11. Start Time
12. Stop Time
13. Final Evaluator
14. Evaluator's Comments
Supersedes DA Form 7595-18-R, MAY 2009
Page 2 of 2
DA FORM 7595-3-1, MAR 2014
APD LC v1.00

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