Part 3– CERTIFICATE OF HEALTH PROFESSIONAL

PART 3 – CERTIFICATE OF HEALTH PROFESSIONAL I, …………………………………………………………………………, a person who may take a sample of blood under the Traffic Act 1987, certify that: [ ] I took a sample of blood from the person identified above at (Name of Hospital/Health Centre) ……………………………...…… at .……… am/pm on (date)………………………………………. 20…..…. and I placed the sample of blood, in approximately equal portions, in [ ] separate containers and secured the caps. I then sealed each container with an adhesive seal bearing the identification number [ ]. I placed [ ] container(s) into the secured blood box and gave [ ] to the person / left with the person's personal effects / placed in collection box (delete as required) with a copy of this completed and signed form. (Approximately half may be made available to the person from whom the sample was taken – s 29AAK(7)). or [ ] I did not take a sample of blood from the person because the person refused consent. or [ ] I was not required to take a sample because I believed on reasonable grounds that: (s 29AAK(5) – indicate which one or more is applicable) [ ] the concentration of alcohol in the person's blood is already known; [ ] the taking of the sample would be detrimental to the person's medical condition; [ ] the injuries of the person were not received in a motor vehicle accident or the motor vehicle accident happened more than 12 hours before the person entered the hospital or health centre; [ ] a period of more than 4 hours has elapsed since the person entered the hospital or health centre. I declare that to the best of my knowledge, the information contained in this form is true and correct. Signature of health professional: ………………………….…………………….. Date: ..………………………………………………………………. Qualification: ………………………………………………………………… NOTE: A COPY OF THIS CERTIFICATE MUST BE GIVEN TO THE PERSON OR LEFT WITH THEIR PERSONAL EFFECTS

Traffic Regulations 1999 75 IMPORTANT – FOR PATIENT’S INFORMATION If a sample of your blood has been taken, it has been divided into portions, in [ ] separate containers. The sample will be analysed for the purpose of analysis by an authorised analyst for the Traffic Act 1987. A container(s) containing approximately half of the sample and marked with the identification number specified in this notice has been made available to you in accordance with the Traffic Act 1987. If you wish to have your portion of the sample independently analysed it will be at your own expense. FAILURE TO COLLECT OR HAVE YOUR PORTION OF THE SAMPLE ANALYSED CANNOT BE USED AS A DEFENCE IN ANY PROCEEDINGS BROUGHT AGAINST YOU. POLICE USE ONLY Police officer removing blood sample (Consisting of [ ] separate containers) Name Signature / / am/pm I/D Number Date Time WHITE COPY GIVEN TO PERSON OR LEFT WITH PERSON’S PERSONAL EFFECTS ONLY REMAINING COPIES TO BE PLACED IN SAMPLE BAG FOR TRANSMISSION TO FORENSIC SCIENCE CENTRE

Traffic Regulations 1999 76 FORM 5 CERTIFICATE ON COMPLETION OF ANALYSIS OF BLOOD SAMPLE (TEST FOR ALCOHOL) I, (name) [ ] an authorised analyst, or [ ] a person employed by (name of organisation) an organisation that is an authorised analyst, certify as follows: (a) on (date) a sealed container bearing the identification number (enter number) , accompanied by the certificate attached to this form, was received at (place of analysis) ; (b) the container contained a sample of blood; (c) an analysis of the sample was carried out and the analysis disclosed the presence in the blood of a concentration of grams of alcohol per 100 ml of blood; (d) I examined the laboratory's records relating to the receipt, continuity of custody and storage of the container and testing of the sample (including the test process) that was done in the laboratory and I confirm the records indicate that all relevant quality assurance procedures were complied with. Date