Traffic Regulations 1999

regulation 61

NORTHERN TERRITORY OF AUSTRALIA

Traffic Regulations 1999

FORM 1

CERTIFICATE ON PERFORMANCE OF BREATH ANALYSIS

I, (operator name) , a police officer authorised by the

Commissioner to use a prescribed breath analysis instrument for the

Traffic Act 1987, certify as follows:

1 At the time of am/pm on the date of

I carried out an analysis on a sample of breath supplied by

(full name and address of person)

(the

subject),

whose occupation is and who is years of age.

2 Before carrying out the analysis I satisfied myself that the subject had not consumed any alcohol within the preceding 15 minutes.

3 Before carrying out the analysis I prepared the breath analysis instrument for use in the manner prescribed by the Traffic

Regulations 1999.

4 I provided an unused mouthpiece for use by the subject in giving the sample.

5 The result of the analysis shown on and recorded by the breath analysis instrument was (strike out whichever not applicable):

6 Within one hour of carrying out the analysis I signed and delivered to the subject a statement as required by regulation 58(2).

Signed

At the time of am/pm on the date of

NORTHERN TERRITORY OF AUSTRALIA

Traffic Regulations 1999

FORM 2

CERTIFICATE ON REFUSAL OR FAILURE TO SUBMIT TO OR PROVIDE A SAMPLE

OF BREATH SUFFICIENT FOR COMPLETION OF BREATH ANALYSIS

I, (operator name) , a police officer who is authorised by the

Commissioner to use a prescribed breath analysis instrument for the purposes of the Traffic Act 1987, certify that:

1. At the time of am/pm on the date of I prepared to perform an analysis on a sample of breath to be supplied by

(full name and address of person)

(the subject),

whose occupation is and who is years of age.

2. I asked if the subject was suffering from any illness and the subject responded "

".

3. I asked if the subject was suffering from any disability and the subject responded "

".

4. I asked if the subject was suffering from any injuries and the subject responded "

".

5. I asked if the subject was taking any tablets, drugs, insulin or medicine and the subject responded "

".

6. I satisfied myself that the subject had not consumed any alcohol within the immediately preceding 15 minutes.

7. I prepared the breath analysis instrument for use in the prescribed manner and satisfied myself that the instrument was in good working order.

8. I provided an unused mouthpiece for use by the subject in giving a sample of breath.

9. I said to the subject "This is a prescribed breath analysis instrument. I am authorised to use it for the purposes of the Traffic

Act 1987. It is in good working order and ready for use. I require you to submit to a breath analysis.".

10. I then gave the subject directions as to how the subject was to provide a sample of breath sufficient for the performance of the breath analysis.

11. The subject then said "

and the subject

(describe the person's actions if relevant)

Signed

At the time of on the date of

NORTHERN TERRITORY OF AUSTRALIA

Traffic Regulations 1999

FORM

3

BLOOD

TEST FOR FORENSIC ANALYSIS

For completion by a medical practitioner, registered nurse, a member of staff of a hospital under direct supervision of a medical practitioner or registered nurse or, if at a health centre, a qualified person.

__________________________________________________________________________

Name of person liable to give sample of blood: …………………………………..

If identity of person unknown, enter Health Registration Number (HRN) ………………………

Person's address (if known): .……………………………………........................

………………………………………………………………………………………….

PART 1 – REASON FOR TEST

Please indicate with an "x" in the appropriate box:

[ ] A police officer required this person to give a sample of blood

(s 29AAG).

Blood to be tested for [ ] Drugs [ ]

Alcohol [ ] Drugs & Alcohol

or

[ ] This person entered this hospital/health centre for examination or treatment of injuries which may have been received in a crash.

(s 29AAK)

Blood to be tested for drugs and alcohol.

PART

2 – STATEMENT BY HEALTH PROFESSIONAL TO PERSON

[ ] "You are required by law to give a sample of your blood for the purpose of analysis. Failure to do so is an offence under the Traffic

Act 1987 (s 29AAH).

Do you consent to me taking a sample of your blood?" Person's answer:

[ ] Yes

……………..………………..……(record person's comment if any)

[ ] No –

"What is the reason for your refusal?"………………………..

or

[ ] I did not make the statement to the person because the person was unconscious or otherwise apparently incapable of giving or refusing consent to the taking of a sample …………………..……………………..

………………………………………………………………………………….

(Record factors which may affect the person's ability to understand the nature of the request, eg: shock, influence of alcohol/drugs, injury, loss of consciousness, mental state, language etc.)

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

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

SCIENCE CENTRE

NORTHERN TERRITORY OF AUSTRALIA

Traffic Regulations 1999

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) ;

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.

Signed

Date

NORTHERN TERRITORY OF AUSTRALIA

Traffic Regulations 1999

FORM 6

CERTIFICATE ON COMPLETION OF ANALYSIS OF BLOOD SAMPLE (TEST FOR

DRUG)

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) ;

the container contained a sample of blood;

an analysis of the sample was carried out and the analysis disclosed the presence in the blood of the following:

*Delta-9-tetrahydrocannabinol (THC)

*Methylamphetamine

*3,4-Methylenedioxymethamphetamine (MDMA)

*Methylenedioxyamphetamine (MDA)

*Monoacetylmorphine (heroin metabolite)

*Benzoylmethylecgonine (cocaine)

*Benzoylecgonine (cocaine metabolite)

*Morphine

*Methadone

*Amphetamine

*Delete items not detected/not tested for

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.

Signed

Date