Victorian Numbered Acts Victorian Numbered ActsSchedule 1—Forms
FORM 1
Instructions for completing this form
This form is to be completed by the co-ordinating medical practitioner for a person who has made a first request for access to voluntary assisted dying. The co-ordinating medical practitioner is required under the Voluntary Assisted Dying Act 2017 to conduct a first assessment of a person who has made a first request.
Use this form to—
(a) notify the Board that the person has made a first request; and
(b) report to the Board the outcome of the first assessment of the person.
Do not complete this form unless you are a registered medical practitioner who is a fellow of a specialist medical college or a vocationally registered general practitioner, and you have completed the approved assessment training.
You must give a copy of this form to the Board within 7 days after completing the first assessment, whether or not you have assessed the person as eligible for access to voluntary assisted dying.
Part A—Details of person who has been assessed
Full name:
Date of birth:
Address:
Contact telephone number:
Part B—Co-ordinating medical practitioner details
Full name:
Practice address:
Practice telephone number:
Email address:
I am a—
o fellow of a specialist medical college
o vocationally registered general practitioner
Year *fellowship awarded/vocational registration granted:
Date approved assessment training last completed:
Co-ordinating medical practitioner's relevant expertise and experience in the person's disease, illness or medical condition (if any)
[ Insert details and specify disease, illness or medical condition ]
Part C—First request
Date on which person requesting access made first request for access to voluntary assisted dying:
Part D—First assessment report
Instructions for completing this Part
If you have assessed the person as eligible for access to voluntary assisted dying—complete section 1 only.
If you have assessed the person as ineligible for access to voluntary assisted dying—complete section 2 only.
Section 1: person assessed as eligible
I, [ insert co-ordinating medical practitioner's name ], have completed an assessment of [ insert name of person being assessed ] and I am satisfied that [ insert name of person being assessed ]—
(a) is aged 18 years or more; and
(b) is an Australian citizen or permanent resident, and is ordinarily resident in Victoria and was ordinarily resident in Victoria for at least 12 months at the time of making a first request; and
(c) has decision-making capacity in relation to voluntary assisted dying; and
(d) has been diagnosed with a disease, illness or medical condition that—
(i) is incurable; and
(ii) is advanced, progressive and will cause death; and
(iii) is expected to cause death within weeks or months, not exceeding 6 months or, in the case of a disease, illness or medical condition that is neurodegenerative, not exceeding 12 months; and
(iv) is causing suffering to the person that cannot be relieved in a manner that the person considers tolerable.
Details of person's diagnosis and prognosis
[ Insert details ]
Was a referral required for a specialist opinion regarding decision-making capacity?
o Yes
o No
If the referral was required, provide details of the referral
[ Insert details of referral ]
Was a referral required for a specialist opinion in relation to the person's disease, illness or medical condition?
o Yes
o No
If a referral was required, provide details of the referral
[ Insert details of referral ]
Was a referral required for a specialist opinion in relation to whether the person's disease, illness or medical condition was a disease, illness or medical condition that is neurodegenerative that would cause death and was expected to cause death between 6 and 12 months?
o Yes
o No
If a referral was required, provide details of the referral and attach a clinical report from that specialist.
I have provided the person being assessed with the following information and I am satisfied that the person understands this information—
(a) the person's diagnosis and prognosis;
(b) the treatment options available to the person and the likely outcomes of that treatment;
(c) palliative care options available to the person and the likely outcomes of that care;
(d) the potential risks of taking a poison or controlled substance or a drug of dependence likely to be prescribed under this Act for the purposes of causing the person's death;
(e) that the expected outcome of taking a poison or controlled substance or a drug of dependence likely to be prescribed under this Act is death;
(f) that the person may decide at any time not to continue the request and assessment process;
(g) that if the person is receiving ongoing health services from a registered medical practitioner other than the co-ordinating medical practitioner, the person is encouraged to inform the registered medical practitioner of the person's request to access voluntary assisted dying.
To the best of my knowledge the person informed the relevant registered medical practitioner of the person's request to access voluntary assisted dying—
o Yes
o No
If No, why not?
[ Specify reasons ]
I have, with the consent of the person, taken all reasonable steps to fully explain to a member of the family of the person, all relevant clinical guidelines; and a plan in respect of the self-administration of a voluntary assisted dying substance for the purpose of causing death.
I am satisfied that the person being assessed is acting voluntarily and without coercion, and that the person's request for access to voluntary assisted dying is enduring.
[ Attach necessary supporting material demonstrating that the person satisfies all the eligibility criteria. ]
Signed
Signature of co-ordinating medical practitioner
Date
Instructions to co-ordinating medical practitioner on assessing person as eligible
If you have assessed the person as eligible for access to voluntary assisted dying, you as the co-ordinating medical practitioner must refer the person to another registered medical practitioner for a consulting assessment.
If the consulting medical practitioner assesses the person as eligible for access to voluntary assisted dying, you are required to perform the remaining tasks of co-ordinating medical practitioner in relation to the request and assessment process (see Divisions 3 to 6 of Part 3 of the Voluntary Assisted Dying Act 2017 ). If, on completion of the final review, you certify that the request and assessment process has been completed, you as the co-ordinating medical practitioner are required to apply for a voluntary assisted dying permit and perform the other tasks required of the co-ordinating medical practitioner, set out in Parts 4 and 5 of the Voluntary Assisted Dying Act 2017 .
Section 2: person assessed as ineligible
I, [ insert co-ordinating medical practitioner's name ] have completed an assessment of [ insert name of person being assessed ] and I am not satisfied that [ insert name of person being assessed ] is eligible for access to voluntary assisted dying.
The person does not satisfy the following requirements of section 20(1) of the Voluntary Assisted Dying Act 2017
[ State relevant eligibility criteria or other requirements of section 20(1) that have not been satisfied . Attach any necessary supporting material demonstrating that the person does not satisfy those criteria or requirements. ]
Signed
Signature of co-ordinating medical practitioner
Date
*delete if inapplicable
FORM 2
CONSULTING ASSESSMENT REPORT FORM
Instructions for completing this form
This form is to be completed by a consulting medical practitioner who has conducted a consulting assessment of a person who has made a first request for access to voluntary assisted dying.
Use this form to report to the Board the outcome of the consulting assessment of the person.
Do not complete this form unless you are a registered medical practitioner who is a fellow of a specialist medical college or a vocationally registered general practitioner and you have completed the approved assessment training.
You must give a copy of this form to the Board within 7 days after completing the consulting assessment, whether or not you have assessed the person as eligible for access to voluntary assisted dying.
You must also give a copy of this form to the co-ordinating medical practitioner.
Part A—Details of person who has been assessed
Full name:
Date of birth:
Address:
Contact telephone number:
Part B—Consulting medical practitioner details
Full name:
Practice address:
Practice telephone number:
Email address:
I am a—
o fellow of a specialist medical college
o vocationally registered general practitioner.
Year *fellowship awarded/vocational registration granted:
Date approved assessment training last completed:
Consulting medical practitioner's relevant expertise and experience in the person's disease, illness or medical condition (if any):
[ Insert details and specify disease, illness or medical condition ]
Part C—Consulting assessment report
Instructions for completing this Part
If you have assessed the person as eligible for access to voluntary assisted dying—complete section 1 only.
If you have assessed the person as ineligible for access to voluntary assisted dying—complete section 2 only.
Section 1: person assessed as eligible
I, [ insert consulting medical practitioner's name ], have completed an assessment of [ insert name of person being assessed ] and I am satisfied that [ insert name of person being assessed ]—
(a) is aged 18 years or more; and
(b) is an Australian citizen or permanent resident, and is ordinarily resident in Victoria and was ordinarily resident in Victoria for at least 12 months at the time of making a first request; and
(c) has decision-making capacity in relation to voluntary assisted dying; and
(d) has been diagnosed with a disease, illness or medical condition that—
(i) is incurable; and
(ii) is advanced, progressive and will cause death; and
(iii) is expected to cause death within weeks or months, not exceeding 6 months or, in the case of a disease, illness or medical condition that is neurodegenerative, not exceeding 12 months; and
(iv) is causing suffering to the person that cannot be relieved in a manner that the person considers tolerable.
Details of person's diagnosis and prognosis
[ Insert details ]
Was a referral required for a specialist opinion regarding decision-making capacity?
o Yes
o No
If the referral was required, provide details of the referral
[ Insert details of referral ]
Was a referral required for a specialist opinion in relation to the person's disease, illness or medical condition?
o Yes
o No
If the referral was required, provide details of the referral
[ Insert details of referral ]
I have provided the person being assessed with the following information and I am satisfied that the person understands this information—
(a) the person's diagnosis and prognosis;
(b) the treatment options available to the person and the likely outcomes of that treatment;
(c) palliative care options available to the person and the likely outcomes of that care;
(d) the potential risks of taking a poison or controlled substance or a drug of dependence likely to be prescribed under this Act for the purposes of causing the person's death;
(e) that the expected outcome of taking a poison or controlled substance or a drug of dependence likely to be prescribed under this Act is death;
(f) that the person may decide at any time not to continue the request and assessment process;
(g) that if the person is receiving ongoing health services from a registered medical practitioner other than the co-ordinating medical practitioner, the person is encouraged to inform the registered medical practitioner of the person's request to access voluntary assisted dying.
To the best of my knowledge the person informed the relevant registered medical practitioner of the person's request to access voluntary assisted dying—
o Yes
o No
If No, why not?
[ Specify reasons ]
I am satisfied that the person being assessed is acting voluntarily and without coercion, and that the person's request for access to voluntary assisted dying is enduring.
[ Attach necessary supporting material demonstrating that the person satisfies all the eligibility criteria. ]
Signed
Signature of consulting medical practitioner
Date
Section 2: person assessed as ineligible
I, [ insert consulting medical practitioner's name ] have completed an assessment of [ insert name of person being assessed ] and I am not satisfied that [ insert name of person being assessed ] is eligible for access to voluntary assisted dying.
The person does not satisfy the following requirements of section 29(1) of the Voluntary Assisted Dying Act 2017
[ State relevant eligibility criteria or other requirements of section 29(1) that have not been satisfied . Attach any necessary supporting material demonstrating that the person does not satisfy those criteria or requirements. ]
Signed
Signature of consulting medical practitioner
Date
*delete if inapplicable
FORM 3
I [ insert name of person making declaration ]
of [ insert address of person making declaration ]
request access to voluntary assisted dying under the Voluntary Assisted Dying Act 2017 . I am advised that I have been assessed as eligible for access to voluntary assisted dying by my co-ordinating medical practitioner and a consulting medical practitioner.
I make this declaration voluntarily and without coercion.
I understand the nature and effect of this declaration, being that if I meet the requirements of the Voluntary Assisted Dying Act 2017 I will be prescribed a voluntary assisted dying substance, and I expect to die when I self-administer or I am administered that substance.
If I am not physically capable of self-administration or digestion of the voluntary assisted dying substance, only my coordinating medical practitioner may administer the voluntary assisted dying substance to me.
Signed
Signature of person making declaration or signing on that person's behalf
Signature of witness 1
Signature of witness 2
Signature of co-ordinating medical practitioner
Date
Note—signing on behalf of person making the declaration
If the person making the declaration is unable to sign it another person may sign the declaration on that person's behalf, at that person's direction and in that person's presence. The person who signs the declaration must be aged 18 years or more and must not witness the declaration.
Note regarding witnesses
Not more than one witness may be a family member of the person making the declaration—see section 35(3) of the Voluntary Assisted Dying Act 2017 . A family member means a person who is a spouse or domestic partner, parent, sibling, child or grandchild of the person making the declaration.
Witness certification—complete this section if declaration signed by person making it
I, [ name of witness 1 ]
of [ insert address of witness 1 ] certify—
(a) that, in my presence, the person making the declaration appeared to freely and voluntarily sign the declaration; and
(b) that, at the time the person signed the declaration the person appeared to have decision-making capacity in relation to voluntary assisted dying; and
(c) that, at the time the person signed the declaration, the person appeared to understand the nature and effect of making the declaration; and
(d) that I am aged 18 years or more; and
(e) that I am not knowingly—
(i) a beneficiary under a will of the person making the declaration; or
(ii) a person who may otherwise benefit financially or in any other material way from the death of the person making the declaration; or
(iii) an owner
of, or a person responsible for the
day-to-day operation of, any
health facility at
which—
(A) the person making the declaration is being treated; or
(B) the person making the declaration resides; or
(iv) directly involved in providing health services or professional care services to the person making the declaration.
Signed
Signature of witness 1
I, [ name of witness 2 ]
of [ insert address of witness 2 ] certify—
(a) that, in my presence, the person making the declaration appeared to freely and voluntarily sign the declaration; and
(b) that, at the time the person signed the declaration the person appeared to have decision-making capacity in relation to voluntary assisted dying; and
(c) that, at the time the person signed the declaration, the person appeared to understand the nature and effect of making the declaration; and
(d) that I am aged 18 years or more; and
(e) that I am not knowingly—
(i) a beneficiary under a will of the person making the declaration; or
(ii) a person who may otherwise benefit financially or in any other material way from the death of the person making the declaration; or
(iii) an owner
of, or a person responsible for the
day-to-day operation of, any
health facility at
which—
(A) the person making the declaration is being treated; or
(B) the person making the declaration resides; or
(iv) directly involved in providing health services or professional care services to the person making the declaration.
Signed
Signature of witness 2
Witness certification—complete this section if another person signed declaration on behalf of person making it
I, [ name of witness 1 ]
of [ insert address of witness 1] certify—
(a) that, in my presence, the person making the declaration appeared to freely and voluntarily direct the other person to sign the declaration; and
(b) that, in my presence and in the presence of the person making the declaration, the other person signed the declaration; and
(c) that, at the time the other person signed the declaration, the person making it appeared to have decision-making capacity in relation to voluntary assisted dying; and
(d) that, at the time the other person signed the declaration, the person making the declaration appeared to understand the nature and effect of making the declaration; and
(e) that I am aged 18 years or more; and
(f) that I am not knowingly—
(i) a beneficiary under a will of the person making the declaration; or
(ii) a person who may otherwise benefit financially or in any other material way from the death of the person making the declaration; or
(iii) an owner
of, or a person responsible for the
day-to-day operation of, any
health facility at
which—
(A) the person making the declaration is being treated; or
(B) the person making the declaration resides; or
(iv) directly involved in providing health services or professional care services to the person making the declaration.
Signed
Signature of witness 1
I, [ name of witness 2 ]
of [ insert address of witness 2] certify—
(a) that, in my presence, the person making the declaration appeared to freely and voluntarily direct the other person to sign the declaration; and
(b) that, in my presence and in the presence of the person making the declaration, the other person signed the declaration; and
(c) that, at the time the other person signed the declaration, the person making it appeared to have decision-making capacity in relation to voluntary assisted dying; and
(d) that, at the time the other person signed the declaration, the person making the declaration appeared to understand the nature and effect of making the declaration; and
(e) that I am aged 18 years or more; and
(f) that I am not knowingly—
(i) a beneficiary under a will of the person making the declaration; or
(ii) a person who may otherwise benefit financially or in any other material way from the death of the person making the declaration; or
(iii) an owner
of, or a person responsible for the
day-to-day operation of, any
health facility at
which—
(A) the person making the declaration is being treated; or
(B) the person making the declaration resides; or
(iv) directly involved in providing health services or professional care services to the person making the declaration.
Signed
Signature of witness 2
Interpreter certification—complete this section if declaration was made with the assistance of an interpreter
I, [ insert name of interpreter ] certify that—
(a) I provided a true and correct translation of any material translated; and
(b) I am an interpreter accredited by [ insert name of accrediting body ]; and
(c) I am not a family member of the person making the declaration; and
(d) I am not knowingly—
(i) a beneficiary under a will of the person making the declaration; or
(ii) a person who may otherwise benefit financially or in any other material way from the death of the person making the declaration; or
(iii) an owner
of, or a person responsible for
day-to-day operation of, any health facility
at
which—
(A) the person making the declaration is being treated; or
(B) the person making the declaration resides; or
(iv) directly involved in providing health services or professional care services to the person making the declaration.
Signed
Signature of interpreter
FORM 4
CONTACT PERSON APPOINTMENT FORM
I, [ insert name of person making the appointment ]
of [ insert address of person making appointment ]
appoint [ insert name of contact person ]
of [ insert address of contact person ]
to be my contact person for the purposes of the Voluntary Assisted Dying Act 2017 .
Signed
Signature of person making appointment or signing on that person's behalf
Date
Note—signing on behalf of person making this appointment
If the person making the appointment is unable to sign it another person may sign this appointment on that person's behalf, at that person's direction and in that person's presence. The person who signs the appointment must be aged 18 years or more, and must not be the contact person or a witness to this appointment.
Contact person's acceptance of appointment
I [ insert name of contact person ] accept the appointment as contact person and understand that this will require me to return any unused or remaining voluntary assisted dying substance to the place of dispensing either at the request of the person making the appointment, or that I know is unused or remaining after the person dies. I understand that it is an offence to fail to return, within 15 days after the death of the person, any voluntary assisted dying substance that I know is unused or remaining.
I also understand that the Voluntary Assisted Dying Review Board may
contact
me to request information.
Signed
Signature of contact person
Witness certification—complete this section if appointment form signed by person making the appointment
I, [ insert name of witness ]
of [ insert address of witness ] certify that this appointment form was signed by the person making the appointment in my presence.
Signed
Signature of witness
Witness certification—complete this section if another person signed appointment form on behalf of person making the appointment
I, [ insert name of witness ]
of [ insert address of witness ] certify that this appointment form was signed in my presence by the other person, at the direction of the person making the appointment.
Signed
Signature of witness
Interpreter certification—complete this section if appointment was made with the assistance of an interpreter
I, [ insert name of interpreter ] certify that—
(a) I provided a true and correct translation of any material translated; and
(b) I am an interpreter accredited by [ insert name of accrediting body ]; and
(b) I am not a family member of the person making the appointment; and
(c) I am not knowingly—
(i) a beneficiary under a will of the person making the appointment; or
(ii) a person who may otherwise benefit financially or in any other material way from the death of the person making the appointment; or
(iii) an owner of, or a person responsible for the day to day operation of, any health facility at which—
(A) the person making the appointment is being treated; or
(B) the person making the appointment resides; or
(iv) directly involved in providing health services or professional care services to the person making the appointment.
Signed
Signature of interpreter
Contact person's contact details
Contact telephone number:
Email address:
FORM 5
Instructions for completing this form
This form is to be completed by the co-ordinating medical practitioner for a person who has made a final request.
Use this form to review and certify whether the request and assessment process has been completed in accordance with the requirements of the Voluntary Assisted Dying Act 2017 .
You must not apply for a voluntary assisted dying permit unless you certify that the request and assessment process has been completed in accordance with the requirements of the Voluntary Assisted Dying Act 2017 .
You must complete this form and give it to the Board whether or not you certify that the request and assessment process has been completed as required by the Voluntary Assisted Dying Act 2017 .
You must attach to this form copies of the following documents—
(a) the first assessment report form;
(b) all consulting assessment report forms;
(c) the written declaration;
(d) the contact person appointment form.
You must give a copy of this form and all required copies of documents to the Board within 7 days of completing this form.
Details of person who has requested access to voluntary assisted dying and is subject of the final review
Full name:
Date of birth:
Address:
Contact telephone number:
Co-ordinating medical practitioner details
Full name:
Practice address:
Practice telephone number:
Email address:
Part A—Details of request and assessment process
Date on which first assessment was completed:
Does the first assessment assess the person as eligible for access to voluntary assisted dying?
o Yes
o No—you must not certify the request and assessment process.
Please attach copy of first assessment report form.
Does a consulting assessment assess the person as eligible for access to voluntary assisted dying?
o Yes
o No—you must not certify the request and assessment process.
Please attach copy of consulting assessment report form.
Full name of consulting medical practitioner who assessed the person as eligible for access to voluntary assisted dying:
Practice address:
Practice telephone number:
Email address:
Date on which consulting assessment was completed:
If more than one consulting assessment was conducted, please attach copies of all other consulting assessment report forms.
Minimum requirements for co-ordinating medical practitioner and consulting medical practitioner who assessed person as eligible for access to voluntary assisted dying
In relation to the co-ordinating medical practitioner and the consulting medical practitioner who assessed the person as eligible for access to voluntary assisted dying—
Are both the co-ordinating medical practitioner and the consulting medical practitioner fellows of a specialist medical college or vocationally registered general practitioners?
o Yes [ specify qualifications held by each practitioner ]
o No—you must not certify the request and assessment process.
Did both the co-ordinating medical practitioner and the consulting medical practitioner complete the approved assessment training before commencing the relevant assessment?
o Yes [ specify date on which each practitioner completed the training ]
o No—you must not certify the request and assessment process.
Does the co-ordinating medical practitioner or the consulting medical practitioner have relevant expertise and experience in the person's disease, illness or medical condition?
o Yes, *the co-ordinating medical practitioner/the consulting medical practitioner [ specify which ]
o No, neither the co-ordinating medical practitioner nor the consulting medical practitioner—you must not certify the request and assessment process.
Does the co-ordinating medical practitioner or the consulting medical practitioner have at least 5 years of experience post fellowship or vocational registration?
o Yes, *the co-ordinating medical practitioner/the consulting medical practitioner [ specify which ]
o No, neither the co-ordinating medical practitioner nor the consulting medical practitioner—you must not certify the request and assessment process.
Date of written declaration:
Has the written declaration been signed by or on behalf of the person making the declaration in accordance with the Act?
o Yes
o No—you must not certify the request and assessment process.
Has the declaration been witnessed in accordance with the Act by 2 witnesses?
o Yes
o No—you must not certify the request and assessment process.
Attach copy of written declaration.
Date of first request:
Date of final request:
Was the final request made at least one day after the day on which the consulting assessment was completed?
o Yes
o No—you must not certify the request and assessment process.
o The final request was made at least 9 days after the day on which the person made a first request.
OR
o The final request was made less than 9 days after the day on which the person made the first request, and—
(a) at time of making the final request, I considered that the person's death was likely to occur within 9 days, and
(b) this assessment was consistent with the prognosis of the consulting medical practitioner who assessed the person as eligible for access to voluntary assisted dying.
Has a contact person been appointed in accordance with sections 39 and 40 of the Act?
o Yes
o No—you must not certify the request and assessment process.
Date of appointment:
Has the contact person appointment form been signed by or on behalf of the person making the appointment in accordance with the Act?
o Yes
o No—you must not certify the request and assessment process.
Has the contact person appointment form been signed by the contact person?
o Yes
o No—you must not certify the request and assessment process.
Has the contact person appointment form been witnessed in accordance with the Act by one witness?
o Yes
o No—you must not certify the request and assessment process.
Attach copy of contact person appointment form.
Based on the information provided above and in the attached forms, has the person been assessed as eligible for access to voluntary assisted dying AND have all requirements of the request and assessment process been completed as required by the Voluntary Assisted Dying Act 2017 ?
o Yes—complete certification in Part B.
o No—you must not certify the request and assessment process. Do not complete certification in Part B.
Part B—Certification of co-ordinating medical practitioner
I, [ insert name of co-ordinating medical practitioner ] certify that the request and assessment process in respect of [ insert name of person requesting access to voluntary assisted dying who is the subject of the final review ] has been completed as required by the Voluntary Assisted Dying Act 2017 .
Signed
Signature of co-ordinating medical practitioner
Date
FORM 6
VOLUNTARY ASSISTED DYING SUBSTANCE DISPENSING FORM
Instructions for completing this form
Use this form to record that a voluntary assisted dying substance has been dispensed on prescription (and provide the details of that prescription) for a person who is the subject of a self-administration permit, and to certify that the required information was given to the person to whom it was dispensed and the labelling statement attached to the voluntary assisted dying substance package or container.
Part A—Pharmacist details
Full name:
Dispensing pharmacy name:
Dispensing pharmacy telephone number:
Place of dispensation:
Part B—Person dispensed the voluntary assisted dying substance
Full name of person named on the prescription:
Address of the person:
Date of birth of the person:
Part C—Prescription details
Prescription authority number (or equivalent):
Date the voluntary assisted dying substance dispensed:
I, [ insert pharmacist's name ] confirm that I have instructed the person to whom the voluntary assisted dying substance was dispensed in accordance with section 58 of the Voluntary Assisted Dying Act 2017 of the following matters—
(a) how to self-administer the voluntary assisted dying substance;
(b) that the voluntary assisted dying substance must be stored in a locked box that satisfies the prescribed specifications;
(c) that the person is not under any obligation to self-administer the voluntary assisted dying substance;
(d) that the person or the relevant contact person must return to a pharmacist at the dispensing pharmacy for disposal any dispensed voluntary assisted dying substance:
(i) that the person has decided to not self-administer; or
(ii) that was not self-administered by the person.
I, [ insert pharmacist's name ] confirm that I attached a label to the voluntary assisted dying substance package or container in the prescribed form in accordance with section 59 of the Voluntary Assisted Dying Act 2017 .
Signature
You must give a copy of this form to the Board within 7 days after dispensing
the voluntary assisted dying substance.
FORM 7
VOLUNTARY ASSISTED DYING
SUBSTANCE DISPOSAL FORM
Instructions for completing this form
Use this form to record that a voluntary assisted dying substance has been returned to the dispensing pharmacy by a person who is the subject of a self-administration permit or their contact person and that it has been destroyed as soon as practicable after its return.
Part A—Pharmacist details
Full name:
Dispensing pharmacy name:
Dispensing pharmacy telephone number:
Place of dispensation:
Part B—Person dispensed the voluntary assisted dying substance
Full name of person named on the prescription:
Address of the person:
Date of birth of the person:
Part C—Person or contact person who returned the voluntary assisted dying substance
Full name:
Address of the person:
Contact telephone number:
Email address:
Part D—Prescription details
Prescription authority number (or equivalent):
Date the voluntary assisted dying substance dispensed:
Date the voluntary assisted dying substance returned:
Voluntary assisted dying substance returned and quantity:
I, [ insert pharmacist's name ] confirm that the voluntary assisted dying substance dispensed to [ insert person's name ] was returned to me, and that in accordance with section 62 of the Voluntary Assisted Dying Act 2017 as soon as practicable after receiving it, I disposed of it.
Signature
You must give a copy of this form to the Board within 7 days after disposing
of the voluntary assisted dying substance.
FORM 8
Sections 65 and 66
CO-ORDINATING MEDICAL PRACTITIONER ADMINISTRATION FORM
Instructions for completing this form
Use this form to record a person's administration request and to certify that the person had decision-making capacity in relation to voluntary assisted dying when the person made the administration request, that the person's request for access to voluntary assisted dying appeared to be enduring and made voluntarily without coercion, and that the person was physically incapable of the self-administration or digestion of the voluntary assisted dying substance.
Further, the purpose of this form is for a witness to the administration of the voluntary assisted dying substance to state that the co-ordinating medical practitioner administered the voluntary assisted dying substance to the person.
Only the co-ordinating medical practitioner for a person is authorised by the Voluntary Assisted Dying Act 2017 to administer the voluntary assisted dying substance to the person in accordance with the Voluntary Assisted Dying Act 2017 .
Part A—Co-ordinating medical practitioner details
Full name:
Practice address:
Practice telephone number:
Email address:
Part B—Details of person making the administration request
Full name:
Date of birth:
Address:
Contact telephone:
Part C—Administration request details
I, [ insert co-ordinating medical practitioner's name ] received an
administration request made in accordance with section 64 of the
Voluntary Assisted Dying Act 2017 [ insert name of person who
made the
administration request ] on [ insert date that the administration request
was made ] at [ insert time at which the administration request was made ] .
Part D—Certification by co-ordinating medical practitioner
Instructions for completing this Part
If you have accepted the person's administration request—complete section 1 only.
If you have refused the person's administration request—complete section 2 only.
Section 1: person's administration request accepted
I certify that, [ insert the person's name ] was physically incapable of the self-administration or digestion of the voluntary assisted dying substance. I certify that their request to access voluntary assisted dying was enduring and made voluntarily and without coercion and that at the time of making the administration request they had decision-making capacity in relation to voluntary assisted dying .
Signature
Reason the person was physically incapable of the self-administration or digestion of the voluntary assisted dying substance:
[ Insert details ]
Section 2: person's administration request refused
I certify that, [ insert the person's name ] at the time of making an administration request to me did not satisfy me of a matter under section 64(1) of the Voluntary Assisted Dying Act 2017 [ insert details of the matter not satisfied ] and I refused the administration request.
Signature
Reason the person did not satisfy a matter under section 64(1) of the Voluntary Assisted Dying Act 2017
[ Insert details ]
Part E—Witness certification
Instructions for completing this Part
Complete this Part if you witnessed the making of an administration request and the administration of the voluntary assisted dying substance to the person.
I, [ insert name of witness ] certify that I witnessed the person make the administration request and at the time of making the administration request—
(a) that the person appeared to have decision-making capacity in relation to voluntary assisted dying; and
(b) the person in requesting access to voluntary assisted dying appeared to be acting voluntarily and without coercion; and
(c) that the person's request to access voluntary assisted dying appeared to be enduring.
Signed
Signature of witness
I, [ insert name of witness ] state that the co-ordinating medical practitioner [ insert co-ordinating medical practitioner's name ] administered the voluntary assisted dying substance to the person.
Signed
Signature of witness
Part F—Administration details—co-ordinating medical practitioner to complete
Date of administration of the voluntary assisted dying substance:
Route of administration of the voluntary assisted dying substance:
Time to unconsciousness:
Time to death:
Complications (if any):
You must give a copy of this form to the Board within 7 days after administering the voluntary assisted dying substance to the person.
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