Western Australian Consolidated Regulations Western Australian Consolidated RegulationsFORM 1
[Reg. 2(1)]
HUMAN REPRODUCTIVE TECHNOLOGY ACT 1991
HUMAN REPRODUCTIVE TECHNOLOGY (LICENCES AND REGISTERS) REGULATIONS 1993
APPLICATION FOR EXEMPTION IN RESPECT OF ARTIFICIAL INSEMINATION PROCEDURES
I
..............................................................................................................................
(Full name of applicant)
of
............................................................................................................................
(Address, fax. and telephone number of applicant)
being a licensed medical practitioner, hereby apply for an exemption from the
licensing requirements of the Human Reproductive Technology Act 1991 in
respect of the carrying out of artificial insemination procedures of the
following kind —
.................................................................................................................
(Specify)
I understand that the conditions specified in s. 33 of the Act will apply
to this exemption.
I undertake —
(a) to
observe and comply with —
(i)
the Code of Practice; and
(ii)
any direction from the Chief Executive Officer of the
Department of Health,
in so far as it
relates to any relevant artificial insemination procedure;
(b) to
furnish such detail as is possible and may be required to —
(i)
the storage licensee from whom sperm was obtained; or
(ii)
if the sperm was not obtained from a storage licensee,
the Chief Executive Officer of the Department of Health,
of the outcome of each
procedure I perform, or authorise, involving donor insemination;
and
(c) to
comply with any requirement made under the Act as to the obtaining of
effective consent from participants.
Signed .........................................
Date ............./............./.............
For further information contact:
Coordinator/Reproductive Technology
Department of Health
189 Royal Street
EAST
PERTH 6004
Phone (08) 9222 4260
Fax (08) 9222 4236
[Form 1 amended in Gazette 15 Dec 2006
p. 5629.]
FORM 2
[Reg. 2(2)]
HUMAN REPRODUCTIVE TECHNOLOGY ACT 1991
HUMAN REPRODUCTIVE TECHNOLOGY (LICENCES AND REGISTERS) REGULATIONS 1993
EXEMPTION IN RESPECT OF ARTIFICIAL INSEMINATION PROCEDURES
This certificate of exemption is issued in accordance with section 28(1)
of the
Act to
......................................................................................................................
(Full name of holder)
of
............................................................................................................................
(Address of holder)
.................................................................................................................................
who, as the person responsible for the supervision of all practices related to
the procedures, has been granted an EXEMPTION from the requirement of the Act
to be licensed to carry out ARTIFICIAL INSEMINATION PROCEDURES of the kind
listed below —
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
subject, in addition to the conditions specified in s. 33 of the Act, to
the following specific conditions —
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
................................................................................................................................
........................................................................
Signed (Chief Executive Officer, Department of Health)
For information contact:
Coordinator/Reproductive Technology
Department of Health
189 Royal Street
EAST
PERTH 6004
Phone (08) 9222 4260
Fax (08) 9222 4236
[Form 2 amended in Gazette 15 Dec 2006
p. 5629.]