NAC50.055. Form of declaration regarding withdrawal of sample of blood.

A declaration referred to in subsection 4 of NRS 50.315 must be in substantially the following form:

     I, ................., hereby declare:

     That I am a ................ (occupation) employed by ................ (employer);

     That a regular part of my duties is the withdrawing of blood samples from persons and I am authorized to do so by the ......................... (name of appropriate licensing or certifying agency);

     That on ......................... (date) at ..... o’clock ...m., I withdrew a sample of blood in a medically accepted manner from a person known to me as ................ (name); and

     That I kept the sample of blood in my sole custody or control and it remained in substantially the same condition as when I first obtained it until on ......................... (date) I delivered the sample to ................ (name of person) of the ................ (name of law enforcement agency).

     I declare under penalty of perjury that the foregoing is true and correct.

Executed on .........................................                .............................................................................

                            (Date)                                                   (Declarant’s Signature)

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

                                                                                             (Declarant’s Title)

     (Added to NAC by Com. on Testing for Intoxication by R112-97, eff. 5-26-98)