Health (Venereal Diseases) Regulations 1973


18/Jul/2003 - Current (at 31 Dec 2005)
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    Appendix

    Form No. 1

    Western Australia

    Health Act 1911

    Health (Venereal Diseases) Regulations 1973

    REQUEST FOR MEDICAL CERTIFICATE


    To

    of

    TAKE NOTICE that, having reason to believe (or having reasonable grounds to suspect) that you are a person suffering from venereal disease, I hereby require you to consult a medical practitioner and to produce to my satisfaction within days of the service upon you of this notice a certificate under the hand of such medical practitioner that you are (or are not) suffering from venereal disease.

    AND FURTHER TAKE NOTICE that if such certificate is not produced within the time stated or, if produced, is not to my satisfaction, a warrant for your compulsory examination may issue.

    Dated at Perth this day of 20 .

EXECUTIVE DIRECTOR,
PUBLIC HEALTH AND SCIENTIFIC SUPPORT SERVICES.

Form No. 2

Western Australia

Health Act 1911

Health (Venereal Diseases) Regulations 1973

WARRANT FOR COMPULSORY EXAMINATION


To ......................................................................

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

Medical Officer of Health (or 2 medical practitioners).

WHEREAS on the day of 20 , a notice issued pursuant to regulation 3 was served upon of requiring him (or her) to consult a medical practitioner and to produce to my satisfaction within days a certificate of such medical practitioner that the said is (or is not) suffering from venereal disease, and whereas the time stated in such notice has expired but the said has not produced the required certificate (or, and whereas the certificate produced by the said is not to my satisfaction).

THESE ARE THEREFORE to authorise and require you forthwith to examine the said to ascertain whether he (or she) is suffering from venereal disease and to report the result of such examination to me.

Given under my hand at Perth this day of , 20 .

EXECUTIVE DIRECTOR,
PUBLIC HEALTH AND SCIENTIFIC SUPPORT SERVICES.

Form No. 3

Western Australia

Health Act 1911

Health (Venereal Diseases) Regulations 1973

WARRANT FOR APPREHENSION AND DETENTION OF PERSON SUFFERING FROM VENEREAL DISEASE


To all Public Health Officials under the Health Act 1911, and to the Officer in Charge of the Gaol Hospital at .

WHEREAS on the day of , 20 , a warrant for the compulsory examination pursuant to regulation 4 of the above regulations, of a person believed or suspected to be suffering from venereal disease was issued but such person failed to attend at the appointed time and place as required by notice, in exercise of the powers conferred upon me by regulation 5 I hereby order you the said Public Health Officials forthwith to apprehend the said and convey him (or her) to for the purpose of examination in accordance with the terms of the warrant aforesaid.

Given under my hand at Perth this day of , 20 .

EXECUTIVE DIRECTOR,
PUBLIC HEALTH AND SCIENTIFIC SUPPORT SERVICES.

Form No. 4

Western Australia

Health Act 1911

Health (Venereal Diseases) Regulations 1973

WARRANT FOR APPREHENSION AND DETENTION OF PERSON SUFFERING FROM VENEREAL DISEASE


To all Public Health Officials under the Health Act 1911, and to the Officer in Charge of the Hospital at .

WHEREAS on the day of , 20 , a warrant for the compulsory examination pursuant to regulation 4 of the above regulations of a person believed or suspected to be suffering from venereal disease was issued and in consequence of such examination it has been reported to me that the said is suffering from venereal disease in an infectious stage and is likely unless detained, to infect other persons.

IN EXERCISE of the powers conferred upon me by section 307 of the Health Act 1911, I hereby order you the said Public Health Officials forthwith to apprehend the said and convey him (or her) to the Hospital
at (or to convey the said from the hospital or other place at which he is now an inmate to the gaol hospital at ) and deliver him (or her) to the officer in charge thereof.

AND I ORDER YOU the officer in charge of the said hospital to receive the said into your care and to detain him (or her) for the period of 2 weeks or until his discharge shall be sooner ordered.

AND I FURTHER ORDER such bacteriological and other examinations and investigations as may reasonably be necessary to be made of and in respect of the said during such detention.

Given under my hand at Perth this day of , 20 .


EXECUTIVE DIRECTOR,
PUBLIC HEALTH AND SCIENTIFIC SUPPORT SERVICES.

Form No. 5

Western Australia

Health Act 1911

Health (Venereal Diseases) Regulations 1973

WARRANT FOR (APPREHENSION AND) FURTHER DETENTION OF PERSON SUFFERING FROM VENEREAL DISEASE


To all Public Health Officials under the Health Act 1911, and to the Officer in Charge of the Hospital at .

WHEREAS on the day of , 20 , a warrant for the apprehension and detention of a person reported to be suffering from venereal disease was issued and pursuant thereto the said was on the day of , 20 , apprehended and conveyed to the hospital at .

AND WHEREAS the period of detention stated in the warrant having expired it appears to me that the said is suffering from venereal disease in an infectious condition and that it is necessary in the interests of the public further to detain the (or WHEREAS the said has absconded from the place of detention aforesaid) I THEREFORE AUTHORISE AND REQUIRE you the said Public Health Officials to apprehend the said and convey him (or her) to the hospital at and deliver him (or her) to the officer in charge thereof and I AUTHORISE AND REQUIRE you the said Officer in Charge of the said hospital to receive the said into your care and to detain the said for a further period of weeks or until his (or her) discharge shall be sooner ordered.

AND I HEREBY DIRECT that the said shall be subject during such detention to any such treatment and examination as I may think necessary in the circumstances.

Given under my hand at Perth this day of , 20 .

EXECUTIVE DIRECTOR,
PUBLIC HEALTH AND SCIENTIFIC SUPPORT SERVICES.

Form No. 6

Western Australia

Health Act 1911 (as amended)

Section 299(2)

NOTIFICATION OF CHANGE OF MEDICAL ADVISER

Date ...........................................

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

    Dr ..........................................................................................................................

    I have to inform you that your former patient ........................................................
    ............................................................................................, who is suffering from
    ....................................................................................................... has now placed
    himself/herself under my care.

.......................................................
Signature of Medical Practitioner.

Form No. 7

Western Australia

Health Act 1911 (as amended)

Part IXA and section 300(1)

NOTIFICATION OF VENEREAL DISEASE


To the Executive Director, Public Health and Scientific Support Services:

I have this day become aware that a person attended or treated by me is suffering from a venereal disease in a non-infectious*/infectious* stage as follows:

Disease:

        o GONORRHOEA

        o GRANULOMA INGUINALE

        o SOFT SORE (chancroid)

        o SYPHILIS (primary)

        o SYPHILIS (secondary)

        o SYPHILIS (early latent)

        o SYPHILIS (late latent)

        o SYPHILIS (tertiary)

        o SYPHILIS (early congenital)

        o SYPHILIS (late congenital)

        o ANOGENITAL WART (new infection)

        o ANOGENITAL WART (recurrence)

        o H.P.V.** CHANGES ON CYTOLOGY AND/OR HISTOLOGY (new infection)

        o H.P.V.** CHANGES ON CYTOLOGY AND/OR HISTOLOGY (recurrence)

    Patient:
        o Male

        o Female

        o o Age
    I believe that I am the first medical practitioner to have been consulted by the abovementioned person for this particular infection.*
Stamp or Block
    Medical practitioner ..................................................................... Letters Please
    Place: ................................................................................
    Date: .................................................................................
    Signature of medical practitioner: ....................................

    *Please delete if inapplicable
    **i.e. Human Papilloma Virus

    Form No. 7A

    Western Australia

    Health Act 1911 (as amended)

    Section 300(1a)

    LABORATORY NOTIFICATION OF POSITIVE VENEREAL DISEASE TEST RESULTS


    To the Executive Director, Public Health and Scientific Support Services:

    Compulsory notification by Clinical Laboratories of the positive results of tests for the detection of venereal disease, pursuant to section 300(1a) of the Health Act 1911 as amended.

    Please tick ALL BOXES of POSITIVE RESULTS:
    NEISSERIA GONORRHOEAE
    Type of TestMICROSCOPY: o
    CULTURE: o
    PENICILLINASE PRODUCTION: o
    Dark Ground Illumination: o
    V.D.R.L. o and Titre:...................
    SYPHILISType of TestF.T.A.(Abs.) o
    T.P.H.A. o
    OTHER TESTS
    DETAILS .......................................
    CHANCROID and GRANULOMA INGUINALEType and Details of Positive Test(s):
    PATIENT'SAgeSexSpecimen
    Laboratory No.
    REFERRING
    DOCTOR
    Name:
    Address:
    NOTIFYING LABORATORYName:
    Address:
    Signature:
    Date:

    Form No. 8

    Western Australia

    Health Act 1911 (as amended)

    Section 301

    NOTIFICATION OF NON-ATTENDANCE
    (VENEREAL DISEASE)


    To the Executive Director, Public Health and Scientific Support Services:

    This is to notify you that a period of 10 days has elapsed since the day on which
    .................................................................................................................................

    (name of patient)
    of ............................................................................................................................
    (address of patient)
    who was suffering from .........................................................................................
    (disease)
    ought to have attended me for treatment, or caused himself to be attended by me for treatment, and failed to do so.

    I have not received notice from any other practitioner that the patient has changed his medical adviser.

Stamp or
    MEDICAL PRACTITIONER ......................................................... Block Letters
    Please

    Place: ..............................................................

    Date: ...............................................................

    Signature of
    Medical Practitioner: ......................................


    Form No. 9

    Western Australia

    Health Act 1911 (as amended)

    Section 303

    CERTIFICATE OF CURE

Date ..........................................
Address .....................................
    I certify that to the best of my knowledge and belief ............................................
    .............................................................................................................is not at this date suffering from venereal disease in any form.
..............................................................
    Signature of Medical Practitioner.



    This certificate is not to be regarded as a guarantee of cure, for the reason that it is frequently impossible to definitely detect evidence of sexual disease. By it, the medical attendant implies that as a result of his observations he can no longer detect signs or symptoms of sexual disease.

    No one should regard himself cured of syphilis unless he has been under active treatment for at least 2 years.

    In the case of gonorrhoea, the cessation of all visible discharge does not of itself definitely indicate that the patient is non-infectious.


    Form No. 10

    Western Australia

    Health Act 1911 (as amended)

    Section 304(2)

    CERTIFICATE OF CURE

Date ..........................................

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

    To the Executive Director, Public Health and Scientific Support Services:

    I certify that to the best of my knowledge and belief ..........................................
    ..............................................is not at this date suffering from venereal disease in an infectious stage.

......................................................
Signature of Medical Practitioner.
    [Appendix amended in Gazette 9 May 1975 p. 1298-9; 4 Jun 1982 p. 1792-3; 29 Jun 1984 p. 1782; 27 Nov 1987 p. 4261.]


Note: This is not an authorised version. The only authorised version is the hardcopy (printed) version published under authority of the Government Printer, available from the State Law Publisher, 10 William St Perth W.A. 6000.