Western Australian Consolidated Regulations Western Australian Consolidated RegulationsForm 1
Western Australia
Road Traffic (Urine Sampling and Analysis) Regulations 1983
(Regulation 7)
Serial No.
I,
.............................................................................................................................
................................................. of
.........................................................................,
Technologist, do hereby certify that the urine sampling equipment contained in
the package Serial No. ...............................................
comprises the items set forth in regulation 6 of the
Road Traffic (Urine Sampling and Analysis) Regulations 1983 and that
those items were prepared by me and are sterile and fit for the purpose of
collecting a urine sample for analysis if used not later than
.............................................................
Dated this ................................... day of
................................................. 20.........
..............................................................
Signature
Note: This package should be opened by cutting along this fold.
Western Australia
Road Traffic (Urine Sampling and Analysis) Regulations 1983
PART 1.
By Medical Practitioner or Registered Nurse:
I,
.............................................................................................................................
duly qualified medical practitioner or registered nurse, hereby certify
that —
1. At the hour of
............................................................................................
m. on the ....................................................... day of
.................................................. 20................. I
collected a sample of the urine of
.................................................. of
...........................................................................................................
portion of which sample is now contained in the enclosed specimen container
numbered..............
2. The equipment used for the purpose of
collecting that urine sample was contained in a package serially numbered
................................................. handed me by
........................................................................................................
and that package was sealed and intact prior to being opened by me.
3. In collecting the urine sample I complied with
regulation 8 of the
Road Traffic (Urine Sampling and Analysis) Regulations 1983 .
.....................................................
Signature and qualification.
PART 2.
By a member of the Police Force:
Name of subject:
....................................................................................................
Medical practitioner or registered nurse:
...............................................................
Time and date of collecting urine sample: .......... .m. on
......................................
Time of occurrence of event giving rise to requirement of urine sample:
....... .m. on the ........................................ of
........................................... 20..............
......................................................................................................
Signature, rank and number.
Form 3
Road Traffic (Urine Sampling and Analysis) Regulations 1983
..........................................................., chief executive
officer of the Chemistry Centre (WA), hereby certify that
..........................................................................................
of
.............................................................................*
is a drugs analyst/* was as at
................................................................ a drugs
analyst.
.............................................................
chief executive officer, Chemistry Centre (WA).
*Delete whichever does not apply.
[Form 3 amended in Gazette 14 Mar 2008
p. 834.]
[Schedule amended in Gazette 29 Jun 1984
p. 1795; 9 Aug 1991 p. 4233; 30 Jan 2001
p. 627; 14 Mar 2008 p. 834.]