Aug. 8.] THE NEW ZEALAND GAZETTE. 2019

(2) Separate lists shall be furnished for each of the following classes:—
(a) Children in attendance at a public school or registered private school:
(b) Children in attendance at a special school or other institution under Part IX of the Education Act, 1914:
(c) Children of school age but not in attendance at any school.

(3) The returns shall be in the Form No. 4 in the Schedule hereto, or to the effect thereof, and shall with respect to every child referred to therein contain the several particulars indicated in the said Form No. 4, so far as such particulars are applicable or are within the knowledge of the Director of Education.

7. The Board established by section 11 of the Mental Defectives Amendment Act, 1928, shall be known as the Eugenics Board (hereinafter in these regulations referred to as “the Board”), and the register to be kept by the Board pursuant to section 14 of that Act shall be known as the Register of Mental Defectives.

8. The decision of the Board to the effect that the name of any person shall be entered on the Register of Mental Defectives shall be communicated to him or to one of his parents, or to his guardian or other person having control of him, as the case may require, in the Form No. 5 in the Schedule hereto.

9. Notice of objection to the decision of the Board that the name of any person should be entered on the Register of Mental Defectives as aforesaid shall be given in the Form No. 6 in the Schedule hereto, and a copy of such form of objection shall be sent by the Board to every person to whom a notice of the Board’s decision is sent.

10. (1) There shall be paid to those members of the Board who are not officers of the Public Service all travelling and locomotion expenses (including the cost of sleeping-berths on trains and deck accommodation on steamers) actually and reasonably incurred by them in attending meetings of the Board, or of any committee thereof, or in transacting any business of the Board.

(2) There shall also be paid to each such member of the Board for every day or part of a day on which he is travelling in connection with the business of the Board the sum of £1 10s. as a travelling-allowance for personal expenses:

Provided that if a member leaves and returns to his usual place of residence on the same day no travelling-allowance shall be paid.

(3) Every claim made by a member of the Board for travelling-allowances or travelling-expenses shall set out the days claimed for, and shall be accompanied by a certificate in the following form:—

I, [Full name, occupation, and address], hereby certify that I was engaged in connection with the business of the Eugenics Board on the days shown in this voucher, and that I incurred the travelling-expenses indicated in the claim.

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SCHEDULE.

Form No. 1.

REQUEST FOR RECEPTION INTO INSTITUTION OF PERSON ALLEGED TO BE MENTALLY DEFECTIVE PRIOR TO MAKING OF RECEPTION ORDER.

Under the Mental Defectives Act, 1911.

To the Superintendent of the [Name of institution], situate at

I, [Full name], a [Occupation], of [Address in full], being a person not under twenty-one years of age, hereby request you to receive [Full name], a [Occupation], of [Address in full] (hereinafter in this request referred to as “the said person”), into the [Name of institution], situate at

, on the grounds that the said person is mentally defective.

1. I believe that the said person is mentally defective on the grounds following [Set out in full the reasons for the applicant’s belief]:

2. I am [Insert degree of relationship, if any, or words “not related”] to the said person, and this request is made by me [Insert “because I am the nearest relative,” or, if applicant is not a relative or nearest relative, state why request is made by the applicant instead of by a relative or a nearer relative, the degree of relationship being determined in the following order: (1) Husband or wife; (2) father or mother; (3) son or daughter; (4) brother or sister; (5) grandfather, grandmother, grandson, or grand-daughter; (6) any other relative.]

3. I last saw the said person on the day of , 19 . [The date herein inserted must be within three days of date of application.]

Dated at , the day of , 19 .

Ordinary signature of applicant:

N.B.—This request must be accompanied by two certificates in the prescribed form, each signed by a medical practitioner.

No person is to be received into an institution in pursuance of such request after the expiration of seven days from the date thereof or from the date of either of the accompanying medical certificates, whichever date is the earlier.

FURTHER PARTICULARS TO BE SUPPLIED BY APPLICANT AS TO PERSON IN RESPECT OF WHOM REQUEST MADE.

Age: Sex:
Whether single, married, widowed, or divorced:
Occupation:
Religious persuasion:
Country of birth:
If not born in New Zealand, date of arrival:
Nationality of parents:
Whether first attack:
If not, age at first attack:
Number of former attacks (if any):
Duration of present attack:
Place of abode at commencement of present attack:
When and where under oversight, care, and control during present attack:
When and where under oversight, care, and control during previous attacks:
Whether epileptic or not:
Whether suicidal or not:
Whether dangerous to others, and (if so) in what way:

Whether any near relative of said person has at any time been or now is of unsound mind, or mentally infirm, or idiot, imbecile, feeble-minded, or markedly eccentric; or has suffered or now suffers from—(a) epilepsy, (b) hysteria, (c) neurasthenia, (d) spasmodic asthma, (e) chorea, or (f) alcoholism. If so, state degree of relationship and particulars as to complaint:—

Relatives of said Person.

In my opinion the following of the above-mentioned relatives are in a position to contribute to the maintenance of the said person:

Name and address of person to whom official communications should be addressed:

Name and address of usual medical attendant of mentally defective person:

Ordinary signature of applicant:

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Form No. 2.

CERTIFICATE OF SUPERINTENDENT IN RELATION TO PERSON RECEIVED INTO INSTITUTION IN ACCORDANCE WITH SECTION 8 OF THE MENTAL DEFECTIVES AMENDMENT ACT, 1928.

To the Stipendiary Magistrate at

I, , being the Superintendent of the [Name of institution], situate at , hereby certify that [Name and description of person to whom certificate relates] was admitted to the said institution at o’clock of the noon on the day of , 19 , in accordance with the provisions of section 8 of the Mental Defectives Amendment Act, 1928, on the written request of , of , supported by two medical certificates signed respectively by and .

As required by the section above referred to, I hereby transmit to you a copy of the request and of the medical certificates aforesaid (each of which I have certified to be a correct copy of the original); and, as further required by the said section, I hereby certify that in my opinion the said is a mentally defective person requiring detention in a mental hospital [or, as the case may be, the said is a mentally defective person, but does not require to be detained in a mental hospital, or the said is not mentally defective].

Dated at , this day of , 19 .

[Signature.]

Superintendent, Mental Hospital.