Transcript

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 organisation’s 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 [email protected] 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 person’s 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: Incumbent’s position title Incumbent’s name

Name of organisation: Rail transport operator (RTO)

Third party service provider

Authorised person’s 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 RTO’s 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 RTO’s appointed authorised persons are required to have knowledge ofthe above standard, including knowledge of the RTO’s 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 person’s 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 person’s 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 person’s 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 6 OF 9(VERSION 3.0 – ISSUED JUNE 2017)

Authorised person’s 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 7 OF 9 (VERSION 3.0 – ISSUED JUNE 2017)

ChecklistPlease ensure you have completed and supplied the following details and items before submitting your documentation:

Page 1 Have read instructions and guidance information

Page 2 (Statutory declaration)

Rail transport operator, or, Third party service provider details provided in the information table

Statutory declaration signed by sub-delegated person and witnessed by 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.

Page 3 on onwards requirements Schedule 1 completed listing the appointed drug and alcohol authorised persons

Attachment requirements Photographs provided are in jpg format (file size recommended limit of 100kb per photograph)

Photograph supplied for each authorised person and the file is named accordingly

Photographs comply with photo guide provided on page 1

PDF copy of the signed Instrument of appointment for each authorised person (these instruments can only be signed by the Drug and Alcohol Sub-delegate)

If notification form and attachments exceeds 10MB, organisations are to forward the information on a CD or flash-drive to ONRSR.

NSW DRUG AND ALCOHOL – NOTIFICATION OF APPOINTMENT OF NSW AUTHORISED TESTING PERSONS | PAGE 8 OF 9(VERSION 3.0 – ISSUED JUNE 2017)

Important information Authorised person (employee) exits operator’s employment (and/or) cancellation of appointment

If a person to whom an identity card has been issued ceases to be an authorised person, the person must return the identity card to the ONRSR (NSW Branch) as soon as practicable. Failure to do so is an offence under the National Rail Safety Legislation.

Complete the, ‘NSW Drug and alcohol identity card – status notification form’ made available on the ONRSR website and email the form to [email protected] marked as:

Subject: NSW D&A Identity Card Notification (Cancelled) – [insert Operator name]

Lost or stolen identity cards

You must advise ONRSR (NSW Branch) as soon as you become aware that your identity card is lost or stolen by completing the, ‘NSW Drug and alcohol identity card – status notification form’ made available on the ONRSR website and email the form to [email protected] marked as: Subject: NSW D&A Identity Card Notification (Lost/stolen) – [insert Operator name] (If you find your identity card after reporting it lost or stolen, you should still return it to the ONRSR)

Expired identity cards (and renewals)

There is an expiration period of approximately 3 years assigned to each card.

The sub-delegated person within your organisation will be contacted by the ONRSR (NSW Branch) 3 months prior to the identity card expiration date for the purpose of renewal of cards.

Expiry and renewal is a separate form and process to the other status types noted on this sheet.

Replacement identity cards

If you are requesting a replacement card because an identity card is lost or stolen, refer to the section above for ‘lost or stolen identity cards’.

If you require a replacement card because a current identity card is illegible or damaged, complete the ‘NSW Drug and alcohol identity card – status notification form’ made available on the ONRSR website and email the form to [email protected] marked as: Subject: NSW D&A Identity Card Notification (Replacement) – [insert Operator name]

The ONRSR (NSW Branch) will replace the damaged or illegible card with a reissue.

The damaged or illegible card must be returned to ONRSR (NSW Branch) after the new card is received.

Post the old damaged/illegible card to:ONRSR (attention NSW Branch) | PO Box 3461, Rundle Mall, Adelaide SA 5000

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


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