Schedule 1

Forms

Current

[r. 2(1) and (2) and 4A]

[Heading inserted: Gazette 18 Sep 2018 p. 3513.]

FORM 1

HUMAN REPRODUCTIVE TECHNOLOGY ACT 1991

HUMAN REPRODUCTIVE TECHNOLOGY 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: Gazette 15 Dec 2006 p. 5629; 18 Sep 2018 p. 3513.]

FORM 2

HUMAN REPRODUCTIVE TECHNOLOGY ACT 1991

HUMAN REPRODUCTIVE TECHNOLOGY 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: Gazette 15 Dec 2006 p. 5629; 18 Sep 2018 p. 3513.]

FORM 3

Human Reproductive Technology Act 1991 s. 55		Warrant authorising entry to premises
To
Application	The applicant has applied under the Human Reproductive Technology Act 1991 s. 55(1) to me, a Justice of the Peace, for a warrant authorising entry to premises.
Applicant’s details	Full name of authorised officer/member of the Police Force
	Office/Rank held		Number assigned for official purposes to applicant
Suspected offence(s)
Purpose of warrant
Warrant	This warrant authorises you to enter the premises described below, with such other persons as may be necessary to assist, and to exercise the powers in the Human Reproductive Technology Act 1991 section 55(2). This warrant authorises the use of such force as may be necessary.
Premises to be entered
Effect of warrant	This warrant continues to have effect until the purpose for which it is granted is satisfied.
Issuing details	Name of Justice of the Peace
	Date		Time
JP’s signature	Issued by me on the above date and at the above time. Justice of the Peace

[Form 3 inserted: Gazette 18 Sep 2018 p. 3514.]

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