Victorian Consolidated Regulations Victorian Consolidated RegulationsFORM 1
Voluntary Assisted Dying Act 2017
APPLICATION FOR SELF-ADMINISTRATION PERMIT
1 Co-ordinating medical practitioner's details
Practice address:
Practice telephone number:
Email address:
Qualifications:
AHPRA registration number:
2 Person in respect of whom the permit is sought
Address:
Date of birth:
3 Poison or controlled substance or drug of dependence to be prescribed or supplied
Address:
Date of birth:
Contact details:
I, [ co-ordinating medical practitioner's nam e], am satisfied that [ name of person ] has decision-making capacity in relation to voluntary assisted dying and that their request for access to voluntary assisted dying is enduring. [ Name of person ] is able to self‑administer and digest the poison or controlled substance or drug of dependence.
I have attached a copy of the completed final review form and all of the completed forms referred to in section 41(1)(a) of the Voluntary Assisted Dying Act 2017 .
I understand that under section 87 of the Voluntary Assisted Dying Act 2017 it is a criminal offence to falsify a form or record required to be made under that Act. It is also a criminal offence under section 88 of that Act to knowingly make a false statement in a report or form that the person knows is false or misleading in a material particular. Both of these offences carry a maximum penalty of 5 years imprisonment or 600 penalty units, or both in respect of a natural person.
Date:
Signed: [ co-ordinating medical practitioner ]
FORM 2
Voluntary Assisted Dying Act 2017
APPLICATION FOR PRACTITIONER ADMINISTRATION PERMIT
1 Co-ordinating medical practitioner's details
Practice address:
Practice telephone number:
Email address:
Qualifications:
AHPRA registration number:
2 Person in respect of whom the permit is sought
Address:
Date of birth:
3 Poison or controlled substance or drug of dependence to be prescribed, supplied and administered
Address:
Date of birth:
Contact details:
I, [ co-ordinating medical practitioner's name ], am satisfied that [ name of person ] has decision-making capacity in relation to voluntary assisted dying and that their request for access to voluntary assisted dying is enduring. [ Name of person ] is physically incapable of the self-administration or digestion of an appropriate poison or a controlled substance or drug of dependence because [ insert reason ].
I have attached a copy of the completed final review form and of all of the completed forms referred to in section 41(1)(a) of the Voluntary Assisted Dying Act 2017 .
I understand that under section 87 of the Voluntary Assisted Dying Act 2017 it is a criminal offence to falsify a form or record required to be made under that Act. It is also a criminal offence under section 88 of that Act to knowingly make a false statement in a report or form that the person knows is false or misleading in a material particular. Both of these offences carry a maximum penalty of 5 years imprisonment or 600 penalty units, or both in respect of a natural person.
Date:
Signed: [ co-ordinating medical practitioner ]
FORM 3
Voluntary Assisted Dying Act 2017
SELF-ADMINISTRATION PERMIT
This self-administration permit is issued to [ full name and address of the co‑ordinating medical practitioner ].
In accordance with section 45 of the Voluntary Assisted Dying Act 2017 , this self-administration permit in respect of [ name of person ] authorises—
(a) [ name of co-ordinating medical practitioner ] for the purpose of causing [ name of person ] death, to prescribe and supply the voluntary assisted dying substance specified in this permit to [ name of person ] that—
(i) is able to be self-administered; and
(ii) is of a sufficient dose to cause death; and
(b) [ name of person ] to obtain, possess, store, use and self-administer the voluntary assisted dying substance; and
(c) in the case of the death of [ name of person ], within 15 days after the date of [ name of person ] death, the contact person specified in this permit—
(i) to possess and store the unused or remaining voluntary assisted dying substance (if any) for the purpose of returning it to a pharmacist at the dispensing pharmacy; and
(ii) to carry and transport the unused or remaining voluntary assisted dying substance to a pharmacist at the dispensing pharmacy; and
(d) in the case that [ name of person ] decides to make a request under section 53 of the Voluntary Assisted Dying Act 2017 , or decides not to self-administer, or in the case of an order made by VCAT to return the voluntary assisted dying substance to the dispensing pharmacy—the contact person specified in this permit—
(i) to possess and store the voluntary assisted dying substance (if any) that has been dispensed to [ name of person ]; and
(ii) to carry and transport the voluntary assisted dying substance to a pharmacist at the dispensing pharmacy.
Co-ordinating medical practitioner's details
Name of medical practitioner:
Address of medical practitioner:
Person in respect of whom this self-administration permit is issued
Name of person:
Address of person:
Voluntary assisted dying substance
|
Name of poison/controlled substance/drug of dependence |
Maximum dose |
| | |
Contact person in relation to this self-administration permit
Name of person:
Address of person:
Date:
Signed: [ Secretary ]
In accordance with section 50 of the Voluntary Assisted Dying Act 2017 this permit comes into force on [ specify date ].
FORM 4
Voluntary Assisted Dying Act 2017
PRACTITIONER ADMINISTRATION PERMIT
This practitioner administration permit is issued to [ full name and address of the co-ordinating medical practitioner ].
In accordance with section 46 of the Voluntary Assisted Dying Act 2017 , this practitioner administration permit in respect of [ name of person ], for the purpose of causing [ name of person ] death, authorises [ name of co‑ordinating medical practitioner ]—
(a) to prescribe and supply to [ name of person ] a sufficient dose of the voluntary assisted dying substance specified in this permit; and
(b) in the presence of a witness, to receive an administration request; and
(c) to possess, use, and administer in the presence of a witness, the voluntary assisted dying substance to [ name of person ] if—
(i) [ name of person ] is physically incapable of the self‑administration or digestion of the voluntary assisted dying substance; and
(ii) [ name of person ] at the time of making the administration request has decision-making capacity in relation to voluntary assisted dying; and
(iii) [ name of person ] in requesting access to voluntary assisted dying is acting voluntarily and without coercion; and
(iv) [ name of person ] request to access voluntary assisted dying is enduring; and
(v) [ name of person ] is administered the voluntary assisted dying substance immediately after making the administration request.
Co-ordinating medical practitioner details
Name of medical practitioner:
Address of medical practitioner:
Person in respect of whom the practitioner administration permit is issued
Name of person:
Address of person:
Voluntary assisted dying substance
|
Name of poison/controlled substance/drug of dependence |
Maximum dose |
| | |
Date:
Signed: [ Secretary ]
In accordance with section 50 of the Voluntary Assisted Dying Act 2017 this permit comes into force on [ specify date ].
FORM 5
Voluntary Assisted Dying Act 2017
LABELLING STATEMENT FOR VOLUNTARY ASSISTED DYING SUBSTANCE—SELF-ADMINISTRATION PERMIT
Warning: If ingested this substance will cause death.
This is a voluntary assisted dying substance and may only be self‑administered by [ insert name of person who is the subject of the self‑administration permit ]. It is a criminal offence under section 84 of the Voluntary Assisted Dying Act 2017 , carrying a maximum penalty of life imprisonment, to knowingly administer this substance to another person.
This substance should only be self-administered in accordance with the instructions of the co-ordinating medical practitioner. Self-administration of this substance otherwise than in accordance with the instructions may result in complications or this substance being ineffective.
This voluntary assisted dying substance must be stored in a locked box that satisfies the specifications prescribed under regulation 10 of the Voluntary Assisted Dying Regulations 2018 .
Dispensing pharmacy:
............................................................................................................................
If there is any unused or remaining voluntary assisted dying substance, the contact person must return the substance to a pharmacist at the dispensing pharmacy within 15 days after the date of the person's death.
If there is a request under section 53 of the Voluntary Assisted Dying Act 2017 , or the person decides not to self-administer this voluntary assisted dying substance, or if there is an order made by VCAT for the return of this voluntary assisted dying substance, the contact person specified in the permit must carry and transport this voluntary assisted dying substance to the dispensing pharmacy.
FORM 6
Voluntary Assisted Dying Act 2017
LABELLING STATEMENT FOR VOLUNTARY ASSISTED DYING SUBSTANCE—PRACTITIONER ADMINISTRATION PERMIT
Warning: If administered this substance will cause death.
This is a voluntary assisted dying substance and may only be administered by [ insert name ] who is the co-ordinating medical practitioner for [ insert name of person who is the subject of the practitioner administration permit ]. It is a criminal offence under section 83 of the Voluntary Assisted Dying Act 2017 , carrying a maximum penalty of life imprisonment, to intend to cause [ name of person ] death by administering this substance and knowingly administering this substance otherwise than in accordance with the practitioner administration permit.
This voluntary assisted dying substance must be stored in a locked box that satisfies the specifications prescribed under regulation 10 of the Voluntary Assisted Dying Regulations 2018 .
Dispensing pharmacy: …………………………………………………….
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