Trt Injection Training Checklist

1. Patient / Training Information

Patient Name

Date of Birth

Age

Training Date

Phone

Preferred Language

Training Type

Trainer / Provider Name

Training Completed By

Who Will Inject?

Caregiver Name, if applicable

2. Prescription / Dose Verification

Medication

Concentration

Prescribed Dose in mg

Prescribed Dose in mL

Frequency

Planned Injection Day(s)

Route Taught

First Dose Given?

Dose / Prescription Notes

3. Supplies Reviewed

Medication vial reviewed Concentration reviewed Syringe size reviewed Drawing needle reviewed Injection needle reviewed Alcohol pads reviewed Bandage/gauze reviewed Sharps container reviewed Medication storage reviewed

Syringe

Drawing Needle

Injection Needle

Sharps Container Available?

Supply Notes

7. Sharps Disposal

Use FDA-cleared sharps container if available Puncture-resistant container if approved/appropriate Do not throw loose needles in trash Do not flush needles Keep sharps away from children/pets Follow local disposal rules

Sharps Disposal Notes

8. Missed Dose Instructions

Do not double dose Call clinic if unsure If shortly missed, take when remembered if appropriate If close to next dose, skip and resume schedule Document missed dose Clinic-specific instruction provided

Specific Missed Dose Instruction

10. Return Demonstration / Competency

Patient Demonstrated Understanding?

Return Demonstration Completed?

Competency Status

Home Injection Approved?

Identified correct medication Identified correct dose in mL Selected appropriate supplies Prepared medication correctly Selected appropriate site Demonstrated injection technique Explained sharps disposal Explained missed dose plan Explained when to call clinic

Return Demonstration Notes

11. Checklist Summary

Click “Review Checklist” or “Generate Note” to review missing items and training readiness.

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Training Status

—

Home Injection

—

Missing Items

—

Safety Status

12. Patient Handwritten Signature

Patient may sign below using mouse, finger, or stylus.

Patient Signature Name Printed

Signature Date

Patient Signature Captured?

Patient signs inside the box above.

13. Trainer / Provider Signature

Trainer Printed Name

Trainer Signature Date

Trainer Signature Captured?

Trainer signs inside the box above.

14. Generated Training Note

Use this as a draft. Review clinically before saving in the EHR.

CY Men’s Health Clinic — TRT Injection Training / Self-Administration Checklist

1. Patient / Training Information

2. Prescription / Dose Verification

3. Supplies Reviewed

4. Route and Injection Site

Route

Sites Reviewed

5. Step-by-Step Technique Reviewed

6. Safety Rules Reviewed