Western Australian Consolidated Regulations

DRUGS OF ADDICTION NOTIFICATION REGULATIONS 1980 - SCHEDULE

Form

Drugs of Addiction Notification Regulations 1980

NOTIFICATION OF ADDICTION TO DRUGS

EXECUTIVE DIRECTOR, PUBLIC HEALTH: ²

This is to notify you pursuant to the Drugs of Addiction Notification Regulations 1980 that I, within 48 hours of the date of this notice, have become aware or suspect that the person whose name and other particulars are set out below is addicted to drugs and is under a condition of health that is a prescribed condition of health for the purposes of the interpretation “prescribed condition of health” in section 289B of the Health Act 1911 (as amended), and that the drug of addiction specified below is the drug of addiction to which this person is addicted.

Name ............................................................................................................

(Full Name)

of ..................................................................................................................

(Full Address)

Occupation ...................................................................................................

Date of Birth ................................................................................................

Drug (or drugs) of addiction ........................................................................

How taken ....................................................................................................

(specify whether by smoking, oral, injection, etc.)

Estimated period for which any drug of addiction has been taken

......................................................................................................................

Is addiction due to medical treatment? ........................................................

Name of medical practitioner giving this notice:

......................................................................................................................

Address ........................................................................................................

Telephone No. .....................................................

Dated this ............................ day of ...................................... 20.....

......................................................................

        Signed.