Victorian Consolidated Regulations

Infertility Treatment Regulations 1997 - SCHEDULE 1

Regulation 13 INFORMATION TO BE RECORDED IN REGISTER KEPT BY LICENSED CENTRE
1. Information in relation to each donor of gametes, zygotes or embryos kept
or stored at the licensed centre, including any known physical abnormalities
of each donor- 1.1. Donor identification code 1.2. Full name of the donor 1.3.
Date of birth of the donor 1.4. Place of birth of the donor (suburb/town and
country) 1.5. Any other name by which the donor is or has been known 1.6. Full
name of the donor's spouse (if any) 1.7. Residential address and contact
telephone number of the donor 1.8. Date on which the residential address and
contact telephone number were given 1.9. Date on and place at which the donor
has provided the gamete(s) 1.10. Date on which the gamete(s), zygote or embryo
of the donor was received by the licensed centre, if applicable 1.11. Sex of
the donor 1.12. Marital status 1.13. Occupation

1.14. Religion (if any) 1.15. Ethnic background of the donor's parents and
grandparents 1.16. Height 1.17. Build 1.18. Donor's blood group 1.19. Any
known physical abnormality, history of mental illness or intellectual
disability of the donor 1.20. Any screening tests undertaken in relation to
item 1.19 and the results of those tests 1.21. Number of children (if any) and
sex of each child 1.22. Reason why the donor made the donation 1.23. Whether
the donor has consented to the use of his or her gametes, or a zygote or an
embryo formed from his or her gametes, in a donor treatment procedure or
research 1.24. Total number of children born from procedures at the licensed
centre using the donor's gametes or a zygote or embryo formed from his or her
gametes.
2. Information in relation to the destruction or disposal at the licensed
centre of any gametes, zygotes or embryos formed outside the body of a woman-
Gametes 2.1. Date on which the gamete was produced 2.2. Donation or reference
number of the gamete 2.3. Date of destruction or disposal of the gamete.
Zygotes and Embryos 2.4. Date on which the zygote or embryo was formed 2.5.
Donation or reference number of the zygote or embryo 2.6. Details of any
observations made in respect of the zygote or embryo following removal from
storage 2.7. Date of destruction or disposal of the zygote or embryo.
3. Information in relation to the formation or attempted formation at the
licensed centre of a zygote or embryo outside the body of a woman- 3.1. Embryo
or zygote reference number 3.2. Licensed centre record number or doctor's
number (or both), or donor identification code of the woman who produced the
oocyte 3.3. Licensed centre record number or doctor's number (or both), or
donor identification code of the man who produced the sperm 3.4. Date(s) on
which the gamete(s) were produced 3.5. Time and date at which sperm and oocyte
were placed together 3.6. Time and date at which fertilisation was confirmed
4. Information in relation to each woman who undergoes a treatment procedure
at the licensed centre and the husband of each woman, including any known
physical abnormality of the woman or her husband- 4.1. Licensed centre record
number or doctor's number (or both) of the woman and her husband 4.2. Full
name of the woman 4.3. Date of birth of the woman 4.4. Full name of the
husband 4.5. Date of birth of the husband 4.6. Occupations of the woman and
her husband 4.7. Details of any physical abnormality in either the woman or
her husband 4.8. In relation to a woman who has given birth to a child as a
result of a previous treatment procedure- (1) the name of the centre where the
treatment procedure was performed (2) the donor code (3) the name and address
of the hospital where the child was born (4) the medical record number of the
hospital where the child was born (5) the full name of the child (6) the date
and, if known, the time of birth of the child (7) the sex of the child (8) the
weight of the child at birth (9) the gestational age of the child at birth
(10) if applicable, a description of any malformation of or other
abnormalities in the child (11) if the child was not liveborn, the reason (12)
whether the birth of the child was a single or multiple birth (13) in relation
to a multiple birth- (a) the place of the child in the order of birth (b) the
total number of births, whether liveborn or not (c) the sex of each sibling
(d) if any of the other children were not liveborn, the reasons, if known.
5. Information in relation to a treatment procedure carried out on a woman at
the licensed centre- 5.1. Patient codes of the woman who is to undergo the
procedure and her husband 5.2. If the procedure involves the use of an embryo
or a zygote, the reference number of that zygote or embryo 5.3. Date and place
of procedure 5.4. Kind of procedure 5.5. Reason for carrying out the procedure
5.6. Name of the doctor who carried out the procedure 5.7. Date treatment
cycle commenced 5.8. Date the gamete, zygote or embryo used in the procedure
was received by the licensed centre and from where it was transferred, if
applicable 5.9. Whether the gamete, zygote or embryo used was thawed or fresh
5.10. Whether the procedure is a donor treatment procedure. If so, whether the
donor was known to the couple 5.11. Date of consent to undergo the procedure
by the woman and her husband, and date of consent to use the gametes, zygotes
or embryos in a donor treatment procedure by the donor and the donor's spouse,
if applicable 5.12. Donor identification codes for any gametes, zygotes or
embryos used 5.13. Whether the embryo was chosen for its sex in order to avoid
disease or genetic abnormality 5.14. Outcome of the procedure.
6. Information in relation to the use of a gamete, zygote or embryo in a
treatment procedure or research at the licensed centre- 6.1. Reference number
or identification code of the person who produced the oocyte that was used in
the research or from which the zygote or embryo that was used was formed 6.2.
Reference number or identification code of the person who produced the sperm
that was used in the research or which was used to form the zygote or embryo
that was used 6.3. Reference number of the zygote or embryo, if applicable
6.4. Date on which gamete was produced or zygote or embryo formed 6.5. If
gametes were used in research, whether the person who produced the gametes
gave consent 6.6. Date of the consent of any person who produced the gametes
used in the research or that were used to form the zygote or embryo used 6.7.
In relation to gametes used to form a zygote for research or in relation to a
zygote or embryo used in research, whether the research was approved and the
approval number 6.8. Title of the research project 6.9. Month, year and place
in which the project commenced 6.10. In relation to research involving the
formation of a zygote, the date and time at which fertilisation was arrested



7. Information in relation to any gametes, zygotes or embryos transferred from
the licensed centre to-

* another licensed centre; or

* an approved doctor (at a place other than a licensed centre)- 7.1. Date of
transfer 7.2. Place to which the gametes, zygote or embryo were transferred
7.3. Person at the licensed centre or approved doctor's premises who
authorised the transfer 7.4. Patient or donor code of the person who produced
the gametes, or of each person who produced the gametes from which the zygote
or embryo was formed 7.5. Date on and place at which the man produced the
sperm, if sperm transferred 7.6. Date on and place at which the woman produced
the oocyte, if oocyte transferred 7.7. Date on and place at which the zygote
or embryo was formed, if zygote or embryo transferred 7.8. Reason for the
transfer.
8. Information in relation to any gametes, zygotes or embryos transferred from
another licensed centre or approved doctor to the licensed centre- 8.1. Date
of transfer 8.2. Place from which gametes, zygote or embryo were transferred
8.3. Person who authorised the transfer 8.4. Patient or donor code of the
person who produced the gametes, or of each person who produced the gametes
from which the zygote or embryo was formed 8.5. Date on and place at which the
man produced the sperm, if sperm transferred 8.6. Date on and place at which
the woman produced the oocyte, if oocyte transferred 8.7. Zygote or embryo
reference number, if zygote or embryo transferred 8.8. Reason for the
transfer.
9. Information in relation to the collection and storage of gametes, zygotes
or embryos at the licensed centre- Collection of gametes 9.1. Reference or
identification code of person who produced the gamete(s) 9.2. Date and place
at which gametes were provided or obtained 9.3. Reason for the collection of
gametes Collection of oocytes 9.4. If stimulatory drugs were used for
collection of oocytes, the drugs used Collection of sperm 9.5. Method of
collection Storage of gametes, zygotes and embryos 9.6. Reference number of
the zygote or embryo 9.7. Donor or patient number of person who produced the
gametes from which the zygote or embryo was formed 9.8. Date placed in
storage, whether at licensed centre or at another licensed centre 9.9. Whether
the gamete, zygote or embryo was obtained or formed on the premises. If not,
the place from which it was transferred

9.10. Place of storage 9.11. Date removed from storage 9.12. Whether an
extension of the storage period was obtained under section 51 or 52 of the Act
and, if so, the extended date.
10. Information in relation to the consent and withdrawal of consent to the
storage and removal from storage of gametes, zygotes or embryos at the
licensed centre- 10.1. Patient or donor number of the person who gave consent
10.2. Date on which any consent or withdrawal of consent by a person and by
his or her spouse was given 10.3. Name and position of any witness to the
consent or withdrawal of consent 10.4. Date that documentation was received at
the licensed centre 10.5. In relation to a consent for storage, the maximum
storage period (if that period is less than 10 years, in the case of gametes,
or 5 years, in the case of zygotes or embryos).
11. Information in relation to transfer into or out of the State of any
gametes, zygotes or embryos which have been or are stored or kept at the
licensed centre- 11.1. Name of the person who produced the gametes, or the
names of each person who produced the gametes from which the zygote or embryo
was formed (or the patient or donor code, if sent from Victoria) 11.2. Whether
consent was given by the person who produced the gametes from which a zygote
or embryo was formed 11.3. Reference number for the zygote or embryo 11.4.
Reason for transfer into or out of the State 11.5. Date of approval by
Authority 11.6. Place to which the gamete, zygote or embryo was sent or
received from 11.7. Date of transfer 11.8. Name of person at the licensed
centre who authorised the transfer 11.9. Date originally placed in storage at
the licensed centre.
12. Information in relation to each consent, objection, withdrawal or lapsing
of consent or objection given under the Act for a treatment procedure or
research carried out at the licensed centre- 12.1. Donor or patient code of
person who gave the consent, withdrawal or objection 12.2. Name of spouse of
the person who gave the consent, withdrawal or objection 12.3. Date on which
the consent, withdrawal or objection was made 12.4. Date the document
evidencing the consent, withdrawal or objection was received by the licensed
centre 12.5. Purpose for which the consent, withdrawal or objection was given
12.6. Name and position of any witness to the documentation 12.7. Name of the
doctor who gave the woman and her husband information under section 10 of the
Act before consent was given (only applicable to a couple consenting to
undergo a treatment procedure)

In relation to a couple consenting to undergo treatment, or a donor and his or
her spouse consenting to the use of gametes, a zygote or embryo in a donor
treatment procedure or in research involving a zygote or embryo- 12.8. Date on
which counselling was first given by an approved counsellor to the person
giving consent 12.9. Date on which counselling in relation to the prescribed
matters was first given by an approved counsellor to each person 12.10. Name
of any approved counsellor who gave that counselling Lapsing of a consent
12.11. Date on which a consent of the person and his or her spouse, if any,
lapses.
13. Information in relation to any amounts paid to a donor in respect of
donations made at the licensed centre- 13.1. Travelling or attendance costs
paid to the donor 13.2. Amount that the donor is reimbursed for medical
expenses 13.3. Dates on which any payments referred to in items 13.1 and 13.2
were made.
14. Information in relation to the outcome of a treatment procedure, where
known, including particulars of a confirmed pregnancy resulting from the
treatment procedure and any miscarriage resulting from the treatment
procedure- 14.1. Patient codes of the woman who underwent the procedure and
her husband 14.2. Whether the treatment procedure was a donor treatment
procedure. If so, the donor identification codes 14.3. Date on which the
procedure was carried out 14.4. Outcome of the procedure.
15. Information in relation to a child born as a result of a treatment
procedure at the licensed centre, if known, including particulars of the birth
of the child and any physical abnormalities of that child- 15.1. Patient codes
of the woman who underwent the procedure and her husband 15.2. Whether the
treatment procedure was a donor treatment procedure. If so, the donor
identification codes 15.3. Date on which procedure was carried out 15.4. Name
of the child 15.5. Date of birth 15.6. Place of birth (full address) 15.7. Sex
of child 15.8. Birth weight 15.9. Gestational age of child 15.10. Any physical
or other abnormality discerned at or about the time of birth 15.11. If the
child was not liveborn, the reason 15.12. Whether the birth was a single or
multiple birth, and if the latter- (1) the place of the child in the order of
birth (2) the sex of each sibling (3) the total number of children of the
birth, whether liveborn or not (4) if any of the children were not liveborn,
the reasons, if known. __________________