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ASSISTED REPRODUCTIVE TREATMENT REGULATIONS 2019 - SCHEDULE 8

Schedule 8—Certification to take donor gametes or embryos produced from donor gametes from Victoria

Regulation 9E(b)

Name of person making the certification:

Certification

For the purposes of section 36(4) of the Assisted Reproductive Treatment Act 2008 (the Act), I [ name of person making the certification ] of [ address of person making the certification ] propose to take *donor gametes/*an embryo produced from donor gametes from Victoria and certify that—

□     the purpose for which the *donor gametes/*embryo produced from donor gametes will be used outside Victoria is consistent with a purpose for which it could be used in Victoria; and

□     the way in which the *donor gametes/*embryo produced from donor gametes will be used outside Victoria is consistent with the way in which it could be used in Victoria; and

□     I have satisfied the following matters—

□     I have provided the person receiving the donor gametes or embryo produced from donor gametes (the receiving party) with a copy of the donor's consent under section 16 of the Act or evidence that the donor has provided the relevant consent;

□     I have sighted—

        (a)     the donor's passport, driver licence or any other identification document displaying the donor's photograph and signature; or

        (b)     a certified copy of the donor's passport, driver licence or any other identification document displaying the donor's photograph and signature;

□     I have provided the receiving party with the following information about the donor—

        (a)     the donor's unique donor identifier (if any

        (b)     the donor's full name;

        (c)     any other name by which the donor is or has been known;

        (d)     the donor's date of birth;

        (e)     the donor's place of birth (suburb or town and country);

        (f)     the donor's sex;

        (g)     the donor's residential address;

        (h)     the donor's phone number;

              (i)     the date on which the donor produced the gametes;

        (j)     the place at which the donor produced the gametes;

        (k)     the donor's blood group;

        (l)     any known genetic abnormality of the donor and, if available, any results of tests undertaken in relation to that abnormality;

        (m)     the number of women who have given birth to children conceived using the donor's gametes or an embryo produced from the donor's gametes, including any current or former partner of the donor;

        (n)     whether the donor has donated, or intends to donate, gametes or an embryo to any other registered ART provider or to a doctor and, if so—

              (i)     the name and address of that registered ART provider; or

              (ii)     the full name and business address of that doctor;

        (o)     the date on which the donor received counselling under section 18 of the Act and the name of the counsellor who provided the counselling;

□     [* if the person is a registered ART provider and the donor gametes were or the embryo produced from the donor's gametes was not produced at the premises of the registered ART provider ] I have provided the receiving party with the date on which the gametes were or the embryo was received by me;

□     [* if the person is a registered ART provider ] I have provided the receiving party with the following information about the donor—

(a)     the date on which I have sighted—

              (i)     the donor's passport, driver licence or any other identification document displaying the donor's photograph and signature; or

              (ii)     a certified copy of the donor's passport, driver licence or any other identification document displaying the donor's photograph and signature;

(b)     the number of children born as a result of a treatment procedure carried out by me using the donor's gametes or an embryo produced from the donor's gametes;

□     [* if the person is a doctor carrying out artificial insemination using the donor gametes ] I have provided the receiving party with the following information about the donor—

(a)     the date on which the donor gametes were received by me;

(b)     the date on which the donor received counselling under section 18 of the Act and the name of the counsellor who provided the counselling;

(c)     the number of children born as a result of artificial insemination carried out by me using the donor's gametes;

□     I have received the name and contact details of the receiving party;    

□     I have provided written notice to the donor of the name and contact details of the receiving party;

□     I have taken all reasonable steps to ensure that at the time of certification, the limit imposed by section 29 of the Act in relation to the use of the *donor gametes/*embryo produced from donor gametes has not been reached.

Details

At the time of making this certification, the following details about the *donor gametes/*embryo produced from donor gametes to be taken from Victoria are accurate—

[ specify the following details ]

(a)     contact details of person making the certification, including telephone number and address;

(b)     if relevant, the name and contact details of the registered ART provider;

(c)     the unique donor identifier(s);

(d)     details about the *donor gametes/*embryo produced from donor gametes, including—

              (i)     number of vials, straws or containers of donor sperm; and

              (ii)     number of donor oocytes; and

              (iii)     number of embryos produced from donor gametes;

(e)     details of the proposed transport or movement of the *donor gametes/*embryo produced from donor gametes, including—

              (i)     the name and contact details of the receiving party including the country in which the receiving party is located; and

              (ii)     the date or proposed date of movement of the *donor gametes/*embryo produced from donor gametes from Victoria; and

              (iii)     the method of transportation.

Declaration

I acknowledge that providing information that I know or believe to be false or misleading is an offence.

Signed: [ signature of person making certification ]

Name: [ print name ]

Date:

Witness Signed: [ signature of witness ]

Witness Name: [ print name ]

Date:

*Delete if inapplicable.

Notes

1.     Section 36(4) of the Act provides the matters that a person must certify before a person takes donor gametes or an embryo produced from donor gametes from Victoria.

2.     Regulation 9D of the Assisted Reproductive Treatment Regulations 2019 prescribes the additional matters that a person making a certification must satisfy for the purposes of section 36(4)(c) of the Act.

Sch. 9 inserted by S.R. No. 141/2024 reg. 23.


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