Nevada Administrative Code
Chapter 50 - Witnesses
Section 50.055 - 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

NRS 50.315