Notification form – Drug and alcohol - ONRSR .Notification form – Drug and alcohol ... Where

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Text of Notification form – Drug and alcohol - ONRSR .Notification form – Drug and alcohol ... Where

  • Notification form Drug and alcohol (NSW only)

    Notification of appointment of NSW Drug and alcohol authorised persons (NSW) Instructions and guidance > Use this form to notify the Office of the National Rail Safety Regulator (ONRSR) NSW

    Branch of the names of persons appointed as authorised persons permitted to undertakeNSW drug and alcohol testing under Division 9 of Part 3 of the Rail Safety National Law (NSW).

    > The organisations D&A sub-delegate is required to complete the Statutory declaration onpage 3 and have it witnessed by a Justice of the Peace or Legal Professional.Note the purpose of the Statutory Declaration is to verify the individual completing this form on behalf of the organisation, and that this individual also validates that D&A authorised persons have satisfied the required criteria.

    > On receipt of the correctly completed form, the ONRSR NSW Branch will issue NSW D&Aidentity cards to the authorised persons listed in the schedule, in accordance with section 125of the Rail Safety National Law (NSW). Authorised persons must produce an identity cardfor inspection on request to any person required by the authorised person to submit to a test.

    > Passport style photographs in electronic format (jpg) of each authorised person must alsoaccompany the notification form to permit the ONRSR NSW Branch to issue identity cards.Each electronic photograph file should clearly identify the name of the authorised persons.

    Photo guide Photographs must be provided in a jpg file

    (if images are scanned, these must be provided in JPG format, not PDF or TIF). Recommended each photograph electronic file size not to exceed 100KB. Recommended PPI (pixels per inch) resolution is 200ppi Recommended image measurement (size) is 800 x 600 pixel Do not trim or crop the photographs. Photographs should be in portrait from top of head to chest.

    Additional requirements Hair out of face Looking straight at camera No head coverings (except for religious purposes) No shadows Plain light coloured background No hands in photograph

    No red eye No flash reflection on glasses or face Nothing obscuring eyes Prescription lenses only, no tinted lenses Good quality images only (not blurred)

    If the photographs provided do not meet requirements, the application may be rejected and a request made for a new photograph to be supplied by the organisation.

    > In addition, a copy of the signed Instrument of appointment for each authorised person namedin Schedule 1 on page 4 must also be supplied with this notification form.

    > The completed form along with electronic attachments can be forwarded by email to theNSW Branch of the ONRSR at DrugandAlcohol@onrsr.com.au marked as;NSW D&A Authorised Person Notification [+ insert organisation name].

    > IMPORTANTThe above supplied email address has a limited receipt capacity of 10MB per email. Ifyour notification form and combined attachments exceeds this limit, organisations are askedto provide their information on a CD or flash-drive and post to:

    ONRSR (attention NSW Branch), PO Box 3461, Rundle Mall, Adelaide SA 5000 accompaniedwith a covering letter marked as:NSW D&A Authorised Person Notification [+ insert organisation name].

    VERSION 3.0 ISSUED JUNE 2017) ONRSR | PO Box 3461, Rundle Mall, Adelaide SA 5000

    National Off ice: 08 8406 1500 | NSW Branch: 08 8406 1514 or 08 8406 1513 | www.onrsr.com.au

  • Statutory Declaration OATHS ACT 1900, EIGHTH SCHEDULE

    Rail transport operator or, Third party service provider - Information

    Name of organisation Postal address Street address Email address Contact numbers Tel: Fax:

    I, "[..............(click&type) sub-delegated person name]" [full name of sub-delegated person under section 124 of RSNL (NSW)]

    hold position of, "[...............(click&type) Position/title]" [position in organisation]

    employed by, "[.........................(click&type) Organisation name]"

    [name of the accredited rail transport operator or third party service provider ]

    do solemnly and sincerely declare that the persons listed in Schedule 1 have satisfied the criteria for appointment as authorised person under section 124 of the Rail Safety National Law (NSW), as specified in Schedule 2 of the Instrument of sub-delegation issued by the Branch Director of the NSW Office of the ONRSR dated [..] :

    [insert date appearing in instrument of sub-delegation]

    And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Oaths Act 1900.

    Declared at [..], [place]

    on [..] [date]

    _____________________________________________ signature of sub-delegated person

    and in the presence of an authorised witness, who states:

    I, [......],a Justice of the Peace (JP) [.....] [full name] [JP identity number]

    certify the following matters relating to the identity of the person making this Statutory declaration: [*please strikethrough any text that does not apply]1. *I saw the face of the person OR

    *I did not see the face of the person because the person was wearing a face covering, but I am satisfied that the person had a special justification for not removing the covering. * I have known the person for at least 12 months OR* I have confirmed the persons identity using an identification document, and the document Irelied on was:

    [If applicable, provide a description of the identification document relied upon]

    _____________________________________________ signature of Justice of the Peace (JP)

    [.....] [date]

    NSW DRUG AND ALCOHOL NOTIFICATION OF APPOINTMENT OF NSW AUTHORISED TESTING PERSONS | PAGE 2 OF 9 (VERSION 3.0 ISSUED JUNE 2017)

    2.

  • Schedule 1 Authorised persons appointed under section 124 of the Rail Safety National Law (NSW)

    Details of sub-delegated person: Incumbents position title Incumbents name

    Name of organisation: Rail transport operator (RTO) Third party service provider

    Authorised persons name

    Title

    Image file name (electronic photograph) Provide the file name for each attached jpg associated with every listed individual

    Name of employer Date training completed

    format: 11/06/2013

    In

    stru

    men

    t of

    appo

    intm

    ent a

    ttach

    ed

    (aut

    horis

    ed b

    y the

    sub-

    deleg

    ate) Person is

    competent in breath testing devices as per AS 3547-1997 1

    Person has knowledge of urine collecting standard AS/NZS 4308:2008 2

    Family name First name Mr/Ms etc

    Yes No Yes No advise Yes or No for each criteria

    1 Where the accredited RTO does not engage the services of a Third party service provider to undertake alcohol testing, the RTOs appointed authorised persons are required to be competent inthe use of breath testing devices that comply with above standard, or a type approved by the Governor by order published in the NSW Gazette for the purposes of the Road Transport (Safety and Traffic Management Act 1999) and/or the Road Transport Act 2013.

    2 Where the accredited RTO does not engage the services of a Third party service provider to undertake urine testing, the RTOs appointed authorised persons are required to have knowledge ofthe above standard, including knowledge of the RTOs procedures that comply with this standard.

    NSW DRUG AND ALCOHOL NOTIFICATION OF APPOINTMENT OF NSW AUTHORISED TESTING PERSONS | PAGE 3 OF 9 (VERSION 3.0 ISSUED JUNE 2017)

  • Authorised persons name

    Title

    Image file name (electronic photograph) Provide the file name for each attached jpg associated with every listed individual

    Name of employer Date training completed

    format: 11/06/2013

    In

    stru

    men

    t of

    appo

    intm

    ent a

    ttach

    ed

    (aut

    horis

    ed b

    y the

    sub-

    deleg

    ate) Person is

    competent in breath testing devices as per AS 3547-1997 1

    Person has knowledge of urine collecting standard AS/NZS 4308:2008 2

    Family name First name Mr/Ms etc

    Yes No Yes No advise Yes or No for each criteria

    NSW DRUG AND ALCOHOL NOTIFICATION OF APPOINTMENT OF NSW AUTHORISED TESTING PERSONS | PAGE 4 OF 9(VERSION 3.0 ISSUED JUNE 2017)

  • Authorised persons name

    Title

    Image file name (electronic photograph) Provide the file name for each attached jpg associated with every listed individual

    Name of employer Date training completed

    format: 11/06/2013

    In

    stru

    men

    t of

    appo

    intm

    ent a

    ttach

    ed

    (aut

    horis

    ed b

    y the

    sub-

    deleg

    ate) Person is

    competent in breath testing devices as per AS 3547-1997 1

    Person has knowledge of urine collecting standard AS/NZS 4308:2008 2

    Family name First name Mr/Ms etc

    Yes No Yes No advise Yes or No for each criteria

    NSW DRUG AND ALCOHOL NOTIFICATION OF APPOINTMENT OF NSW AUTHORISED TESTING PERSONS | PAGE 5 OF 9(VERSION 3.0 ISSUED JUNE 2017)

  • Authorised persons name

    Title

    Image file name (electronic photograph) Provide the file name for each attached jpg associated with every listed individual

    Name of employer Date training completed

    format: 11/06/2013

    In

    stru

    men

    t of

    appo

    intm

    ent a

    ttach

    ed

    (aut

    horis

    ed b

    y the

    sub-

    deleg

    ate) Person is

    competent in breath testing devices as per AS 3547-1997 1

    Person has know