| (Rule 97(4)) |
| Date .......................................... |
| REMOVAL OF PRISONERS TO HOSPITAL UNDER SECTION 30 OF THE PRISONS ACT, CHAP.16.02 |
|
| Name ........................................ | Age on conviction ............... |
| Court ........................................ |
| Offence ........................................ |
| Sentence ........................................ | Date |
| Number of previous convictions ........................................ |
| .................................................................................................................... |
| .................................................................................................................... |
| .................................................................................................................... |
| (1) |
| Here state condition and whether treatment or operation is recommended. | I have to report that the above named prisoner is suffering from |
| I recommend removal to |
| Here state which Hospital. | and certify that he or she is in a fit state of health to be removed. |
| The prisoner is willing to undergo |
| Here state treatment or operation. | and understand that removal does not mean discharge. |
| ......................................................... |
| Medical Officer. |
| (2) |
| Here delete words not required. | Submitted and recommended. I consider that judging from the prisoner's past record and from his or her behaviour in prison a guard ........................................ required, and I have arranged accordingly. |
| ......................................................... |
| Superintendent of Prisons. |
| (3) |
| Transfer approved by order of the Governor General. |
| ......................................................... |
| Governor General. |
| (4) |
| Progress in hospital of prisoner to be recorded after each month of absence on this paper. |
| .............................................................. |
| Officer in charge of Hospital. |
| The prisoner was transferred to hospital on .................................................... |
| Returned to prison on ...................................................................................... |
| ............................................................. |
| Superintendent of Prisons. |