Western Australian Repealed Regulations

This legislation has been repealed.

NURSES RULES 1993 - SCHEDULE 1

FORM 1

[Rule 3(2)]

APPLICATION FOR HONORARY REGISTRATION AS A NURSE UNDER THE NURSES ACT 1992

THIS FORM MUST BE COMPLETED, SIGNED & RETURNED TO:

NURSES BOARD OF WESTERN AUSTRALIA

FOR OFFICE USE ONLY

Identification No.

Date of Registration

PREFERRED TITLE:

SURNAME:					GIVEN NAMES:
FORMER NAME(S):		PLACE OF BIRTH:             (town)         (country)					DATE OF BIRTH:
RESIDENTIAL ADDRESS: TELEPHONE NO. ......................................................					POSTAL ADDRESS FOR CORRESPONDENCE:
NURSING EDUCATION I completed my nursing education as detailed below:         COURSE
Area of nursing practice	School of Nursing		Location (City & Country)			Date Commenced		Date Completed
REGISTRATION Please list first and current registrations
Category of registration	Name of registering authority			Registration No.			Registration date

I declare that the statements above are true and correct in every particular.

....................................................         ....................................
(Signature)         (Date)

Applicant to be recommended by Head of School of Nursing or Director of Nursing of sponsoring institution.

Applicant will be required to show evidence of identity.

        [Form 1 amended in Gazette 4 May 2001 p. 2243.]

FORM 2

[Rule 10(a)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence that you have been registered in Western Australia.

Issue date:         Expiry date:

This is to certify that ..................................................................... has been registered in — 

DIVISION 1	by virtue of	No.

in accordance with section 22 of the Nurses Act 1992 .

.........................         ........................................         ........................
Signature         Presiding member of         Registrar
of nurse         the Board

        [Form 2 amended in Gazette 4 May 2001 p. 2243.]

FORM 2A

[Rule 10(aa)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence that you have been registered in Western Australia.

Issue date:         Expiry date:

This is to certify that ............................................................................... has been registered in — 

DIVISION 1	by virtue of	No.

in accordance with section 22A of the Nurses Act 1992 .

.........................         ........................................         ........................
Signature         Presiding member of         Registrar
of nurse         the Board

        [Form 2A inserted in Gazette 29 Aug 2003 p. 3841.]

FORM 3

[Rule 10(a)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence that you have been registered in Western Australia.

Issue date:         Expiry date:

This is to certify that ..................................................................... has been registered in — 

DIVISION 2	by virtue of	No.

in accordance with section 22 of the Nurses Act 1992 .

.........................         ........................................         ........................
Signature         Presiding member of         Registrar
of nurse         the Board

        [Form 3 amended in Gazette 4 May 2001 p. 2243.]

FORM 4

[Rule 10(b)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence that the body corporate has been registered in Western Australia.

Issue date:         Expiry date:

This is to certify that ..................................................................... has been registered in — 

DIVISION 3

No.

in accordance with section 24 of the Nurses Act 1992 .

Conditions or restrictions:

.........................         ........................................         ........................
Signature of         Presiding member of         Registrar
principal executive         the Board
officer

        [Form 4 amended in Gazette 4 May 2001 p. 2243.]

FORM 5

[Rule 10(c)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF HONORARY REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence of registration in Western Australia.

Issue date:         Expiry date: .

This is to certify that ............................................................................... has been granted honorary registration in — 

DIVISION 4	by virtue of	No.

in accordance with section 25 of the Nurses Act 1992 .

Conditions or restrictions:

.........................         ........................................         ...............................
Signature         Presiding member of         Registrar
of nurse         the Board

FORM 6

[Rule 10(d)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF PROVISIONAL REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence of registration in Western Australia.

Issue date:         Expiry date: .

This is to certify that ............................................................................... has been granted provisional registration in — 

DIVISION 5	by virtue of	No.

in accordance with section 26 of the Nurses Act 1992 .

Conditions or restrictions:

.........................         ........................................         ........................
Signature         Presiding member of         Registrar
of nurse         the Board

FORM 7

[Rule 10(e)]

NURSES BOARD OF WESTERN AUSTRALIA

CERTIFICATE OF TEMPORARY REGISTRATION

This certificate of registration covers practice until the expiry date shown.

It must be retained following the expiry date as evidence of registration in Western Australia.

Issue date:         Expiry date: .

This is to certify that.................................................................................has been granted temporary registration in — 

DIVISION 6	by virtue of	No.

in accordance with section 27 of the Nurses Act 1992 .

Conditions or restrictions:

.........................         ........................................         .......................................
Signature         Presiding member of         Registrar
of nurse         the Board

FORM 8

[Rules 16 and 17]

APPLICATION FOR RESTORATION OF NAME TO THE REGISTER
(by a natural person)

NURSES BOARD OF WESTERN AUSTRALIA

FORMER NAME(S) _____________________ DATE OF BIRTH _______________________

NOTE: AN APPLICANT APPLYING FOR RESTORATION OF A NAME TO THE REGISTER MUST INDICATE CHANGES THAT HAVE OCCURRED SINCE THE INITIAL REGISTRATION

Change of address must be notified in writing as soon as practicable
(Section 38(2) Nurses Act 1992 )

Change of name on the register can only be effected on production of the appropriate documentation.

TITLE NAME ADDRESS

_______________________________ _______________________________ _______________________________ ___________ Post Code __________

FORMER NAME(S) ____________ DATE OF BIRTH ____________________

(Fee $ )

I request restoration of my name to the register as a nurse — circle the areas of practice which apply.

DIVISION 1         General	Midwifery	Mental Health
DIVISION 2         Enrolled         Other:	Enrolled comprehensive	Enrolled mental health

RECENCY OF PRACTICE

I am practising/last practised nursing in the following area of nursing specialty/specialities.

STATE MONTH AND YEAR of last practice for each area of nursing practice for which you are applying.

AREA OF NURSING PRACTICE	DATE LAST PRACTISED. (Exclude Renewal of Registration Courses)	LOCATION CITY/ COUNTRY	DATE LAST PRACTISED IN WA (Exclude Renewal of Registration Courses)	DATE LAST REGISTERED IN W.A.
General
Midwifery
Mental health
Enrolled
Enrolled Comprehensive
Enrolled mental health
Mothercraft
Dental
Children’s
Tuberculosis

PLEASE ANSWER QUESTIONS ON NEXT PAGE OF THIS FORM

Please indicate “yes” or “no” to the following questions.

If “yes”, please give details in the space below.

1.         Have you ever been convicted in this State or elsewhere of an offence?	.............
2.         Have you ever had any previous registration as a nurse cancelled?	.............
3.         Have you ever been refused registration as a nurse in Western Australia or elsewhere?	.............
4.         Have any of the qualifications upon which you rely for registration as a nurse been withdrawn or cancelled?	.............
5.         Have you at any time been found guilty of unethical conduct as a nurse and/or subject to any disciplinary action by a tribunal or any body or authority legally constituted to discipline nurses?	.............
6.         Are you currently dependent on alcohol or any other drug to an extent that affects your ability to practise as a nurse?	.............
7.         Do you suffer from any mental or physical disorder that is relevant to your ability to practise as a nurse?	.............

RECENCY OF PRACTICE

Where a nurse has not practised nursing within the 5 years preceding the date of the application for renewal, in a division of the register for which registration is sought, the nurse is required to satisfactorily complete a renewal of registration course (sections 22 and 42 Nurses Act 1992 ). If you have completed a renewal of registration course in the last 5 years please complete the details below:

.................         .............................         ............................         ....................................
(Date)         (Hospital/Institution)         (Duration)         (Division of Nursing)

.................         .............................         ............................         ....................................
(Date)         (Hospital/Institution)         (Duration)         (Division of Nursing)

.................         .............................         ............................         ....................................
(Date)         (Hospital/Institution)         (Duration)         (Division of Nursing)

DECLARATION

I do solemnly and sincerely declare that the statements made by me on this form and on any attachment, are true and correct in every particular and that I am the person named in the attached documents.

I make this statement knowing that I am liable under the Nurses Act 1992 , in case of falsehood, to a fine of $2 500.

...........................         ....................................
(Date)         (Signature)

        [Form 8 amended in Gazette 4 May 2001 p. 2243; 30 Dec 2004 p. 6987.]

FORM 9

APPLICATION FOR RESTORATION OF NAME TO THE REGISTER
(by a body corporate)

[Rules 16 and 17]

THIS FORM MUST BE COMPLETED, SIGNED & RETURNED TO:

NURSES BOARD OF WESTERN AUSTRALIA

FOR OFFICE USE ONLY

Identification No.

Date of Registration

NOTE: AN APPLICANT APPLYING FOR RESTORATION OF A NAME TO THE REGISTER MUST INDICATE CHANGES THAT HAVE OCCURRED SINCE THE INITIAL REGISTRATION

APPLICANT’S NAME :

POSTAL ADDRESS : Post Code ( ) Telephone ( )

THE APPLICANT INTENDS TO CONDUCT ITS BUSINESS UNDER THE BUSINESS NAME OF: NATURE OF BUSINESS :

Date of incorporation : _____________________ (where applicable)

PLACES OF BUSINESS IN WESTERN AUSTRALIA :             (a)         PRINCIPAL PLACE OF BUSINESS Post Code ( )

(b)

(c)

(d)

(e)

DECLARATION

I HEREBY DECLARE THAT —

            (a)         the preceding statements are true in every particular to the best of my knowledge, information and belief. I make this Statement knowing I am liable under the Nurses Act 1992 in case of falsehood to a fine of $2 500;

            (b)         I am authorised by the applicant to make this application for and on behalf of the applicant;

            (c)         I undertake to notify the Nurses Board of Western Australia of any changes in particulars contained within the application for registration not later than 7 days after the event;

            (d)         I undertake to produce to the Nurses Board of Western Australia such information as it may from time to time require by written request regarding the affairs of the applicant;

            (e)         full personal professional responsibility for the conduct of the affairs of the applicant in relation to the practice of nursing is, and will remain, an obligation of each member who is a registered nurse and that no person other than a registered nurse has authority over professional matters.

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

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

(Signature of principal executive officer

for and on behalf of the applicant)

•        

•        

•        

OFFICE USE ONLY						SIGHTED		DATE
•         MEMORANDUM AND ARTICLES OF ASSOCIATION
•         IDENTITY OF MEMBERS OF APPLICANT (NON-NURSES)					1
BIRTH CERTIFICATE					2
PASSPORT					3
DRIVER’S LICENCE					4
•         2 CHARACTER REFERENCES FOR DIRECTOR         OR OFFICER OF APPLICANT         (NON-NURSES)					1
					2
					3
					4
•         TERMS OF CONTRACT OF BODY CORPORATE
•         TRUST DEED
•         EVIDENCE OF RESERVATION OF BUSINESS NAME (CORPORATE AFFAIRS)
•         FEE
•         CERTIFICATE OF INCORPORATION
•         EXTRACT OF REGISTRATION OF BUSINESS NAME
•         EVIDENCE OF REGISTRATION OF NURSE MEMBERS
DETAILS OF THE PRINCIPAL EXECUTIVE OFFICER OF THE BODY CORPORATE WHO MUST BE A NURSE:
NAME:		INITIAL REGISTRATION NO/DATE: PRACTISING CERTIFICATE: EXPIRY DATE:
ADDRESS:
DETAILS of the NURSE in whom control of the affairs of the applicant is vested:
NAME: ADDRESS:		INITIAL REGISTRATION NO/DATE: PRACTISING CERTIFICATE: EXPIRY DATE:
DETAILS OF ALL MEMBERS OF THE APPLICANT WHO ARE NURSES:
NAME/DESIGNATION	ADDRESS		INITIAL REG. NO/DATE				PRACTISING CERTIFICATE EXPIRY DATE
(a) (b) (c) (d)
DETAILS OF ALL MEMBERS OF THE APPLICANT WHO ARE NOT NURSES:
NAME	ADDRESS			OCCUPATION
(a) (b) (c)

EXTRACT FROM THE NURSES ACT 1992

SCHEDULE 2

REQUIREMENTS FOR REGISTRATION OF A BODY CORPORATE

1.         Where the body corporate has —

            (a)         more than 2 members, the majority of the members shall be nurses;

            (b)         only 2 members, one member shall be a nurse and the other need not be a nurse but shall be a person of good character,

        but in no case may a body corporate be a member.

2.         The body corporate shall have a place of business within the State.

3.         The principal executive officer of the body corporate shall be a nurse.

4.         Control of affairs of the body corporate shall be vested in a nurse.

5.         The power of persons —

            (a)         to exercise, or to control the exercise of, the rights to vote attached to shares in the body corporate; or

            (b)         to dispose of, or to exercise control over the disposal of such shares,

        shall be such that the personal supervision and management of the affairs of the body corporate cannot become vested in a person who is not a nurse.

6.         Full personal professional responsibility for the conduct of the affairs of the body corporate in relation to the practice of nursing shall remain an obligation of each member who is a nurse and no person other than a nurse may have authority over professional matters.

7.         Proper and adequate provision shall be made for disclosure to the Board of the affairs of the body corporate, on request in writing by the Board to any member who is a nurse, or an undertaking to that effect shall be given to and accepted by the Board.

8.         The memorandum and articles of association of the body corporate shall be acceptable to the Board and contain a provision that the Board be notified of any intention to amend the memorandum or articles and be furnished with a copy of any proposed resolution or other form of proposal to give effect to that intention.

9.         The Board shall be satisfied that there are no other grounds upon which the applicant for registration ought to be refused.

LIABILITY OF MEMBERS OF BODY CORPORATE section 81

(1)         Where a body corporate is convicted of an offence against this Act, every person who at the time of the commission of the offence was a member of the body corporate or an officer concerned in the management of it and who authorised or permitted the commission of the offence is guilty of the like offence.

(2)         A person referred to in subsection (1) may, on request of the complainant, be convicted in the proceedings in which the body corporate is convicted if the court is satisfied that the person had reasonable notice that the complainant intended to make that request.

(3)         Any civil liability in connection with the practice of nursing incurred by a body corporate that is registered under this Act is enforceable jointly and severally against the body corporate and any person who at the time that the liability was incurred was a member of the body corporate.

NOTE:         APPLICANTS ARE ADVISED TO PURCHASE AND BE CONVERSANT WITH THE NURSES ACT 1992 .

DOCUMENTARY REQUIREMENTS TO BE ATTACHED HEREWITH:

1.         A copy of the proposed memorandum and articles of association of the applicant (Note the requirements of Schedule 2 clause 8).

2.         Evidence as to the identity of members of the applicant who are not registered nurses.

3.         Two character references for each member of the applicant who is not a registered nurse.

4.         Evidence of registration of the registered nurses who are members of the applicant.

5.         Trust deed setting out the terms of the trust where shares in the body corporate are held by any person who is not a registered nurse.

6.         Evidence that the proposed business name has been reserved at the office of the State Corporate Affairs.

7.         The prescribed application and registration fees.

8.         THE PROPOSED TERMS OF CONTRACT OF THE BODY CORPORATE TO BE PROVIDED AS SOON AS PRACTICABLE AFTER ISSUE:

              •         A certified copy of the certificate of incorporation of the body corporate.

              •         A certified extract of the registration of the business name.

        [Form 9 amended in Gazette 4 May 2001 p. 2243.]

FORM 10

[Rule 41]

EVIDENTIARY CERTIFICATE

The Nurses Board of Western Australia

This is to certify that .............................................................................................
of.............................................................................................................................
*was / was not registered as a nurse under the Nurses Act 1992 on ..................... ................................................................................................................................
Registration *was / was not suspended on ............................................................

Issued on behalf of the Nurses Board under
section 80(4)(a) of the Nurses Act 1992 .

................................................
Registrar

*DELETE WHERE INAPPLICABLE