Commonwealth of Australia

STATUTORY DECLARATION
Statutory Declarations Act 1959

1 Insert the name,

address and
occupation of
person making the
declaration

2 Set out matter

declared to in
numbered
paragraphs
I,1 am Dr. Rathnayake available in general medical wards. Patients are admitted to the unit from the Outpatient Department (OPD),
Mudalige Nipuni referred by consultant specialists, transferred from general practitioners and peripheral healthcare facilities,
Githmee, living in No or stepped up from medical wards when closer monitoring and higher levels of care are required. The unit
72/1/1 Kapuhena also manages critically ill patients when Intensive Care Unit (ICU) beds are unavailable .
Road, Yakkala Road,
Gampaha, Sri lanka. My responsibilities include the independent assessment and management of patients presenting with acute
Currently working as a medical conditions. This involves obtaining comprehensive medical histories, performing physical
Doctor. examinations, formulating differential diagnoses, requesting and interpreting appropriate investigations,
initiating evidence-based treatment, and monitoring clinical progress. I regularly liaise with consultant
physicians and other specialists, escalating care and arranging specialist review when clinically indicated.
Patients presenting with clinical deterioration or instability are promptly assessed, stabilized, and managed in
accordance with established clinical protocols.
make the
following I independently managed patients across all age groups, including children, adults, and older adults,
declaration under presenting with a wide range of acute, chronic, and preventive healthcare needs. Common conditions
section 9 of the encountered in the Outpatient Department (OPD) included upper respiratory tract infections, pharyngitis,
Statutory urinary tract infections, gastroenteritis, viral febrile illnesses, musculoskeletal disorders and pain syndromes,
Declarations Act wounds, cuts and lacerations, animal bites, acne, fungal infections, and the ongoing management of chronic
1959: diseases such as diabetes mellitus, hypertension, and dyslipidaemia.
2
My clinical duties extended to the provision of preventive and chronic disease care through Non-
I have been employed Communicable Disease (NCD) clinics, where I managed patients with diabetes mellitus, hypertension, and
as a full-time Medical dyslipidaemia. In addition, I contributed to Well Woman Clinics and Immunization Clinics, delivering
Officer in the High screening services, preventive healthcare interventions, vaccinations, counselling, and health promotion
Dependency Unit activities. As one of only two Medical Officers at the hospital, I shared responsibility for a range of
(HDU) at the Colombo administrative functions. These included preparing staff duty rosters, coordinating clinical services, supporting
North Teaching hospital operations, organizing community health awareness campaigns, conducting patient education
Hospital, Sri Lanka, programs, and contributing to the overall administration and smooth functioning of the institution.
since 20 September
2023 and continue to Although a detailed employment verification letter outlining my full scope of duties was requested, I was
hold this position. unable to obtain such a document from my previous place of employment due to limitations in human
Colombo North resources and the heavy clinical workload within the institution. However, I have been able to obtain a
Teaching Hospital is supporting letter from my current workplace, which includes confirmation of all positions I have held under
one of the largest the Ministry of Health, Sri Lanka. This document provides relevant employment verification details that
tertiary teaching support and help validate the information provided in this statutory declaration.
hospitals in Sri Lanka
and functions under
the Ministry of Health.
My regular working
hours are from 8:00
a.m. to 12:00 noon and
2:00 p.m. to 4:00 p.m.
on weekdays, and from
8:00 a.m. to 12:00
noon on Saturdays,
amounting to a total of 3 Signature of person making the declaration
34 hours per week.
The High Dependency
Unit consists of six
beds and provides
close monitoring and I believe that the statements in this declaration are true in every particular, and I
advanced medical care
understand that a person who intentionally makes a false statement in a statutory
for patients requiring a
higher level of declaration is guilty of an offence under section 11 of the Statutory Declarations Act
observation and 1959, the punishment for which is imprisonment for a term of 4 years.
treatment than is 3

4 Email address of 4 nnnipuni@[Link]

telephone number of
person making the
declaration

5 Place
6 Day Declared at 5
on 6
of 7

7 Month and
year

Observed by me,
 8 Signature of person 8

observing the
declaration being
made

9 Full name, qualification

9 and address of
person observing the
declaration being made

10 Email address and/or 10

telephone number of person observing the declaration being made

A statutory declaration under section 9 of the Statutory Declarations Act 1959 may be made before–

(1)a person who is currently licensed or registered under a law to practise in one of the following occupations:
Architect Chiropractor Dentist
Financial adviser Financial Planner Legal practitioner
Medical practitioner Midwife Migration agent registered under Division 3 of Part 3 of the Migration
Act 1958
Nurse Occupational therapist Optometrist
Patent attorney Pharmacist Physiotherapist
Psychologist Trade marks attorney Veterinary surgeon

(2)a person who is enrolled on the roll of the Supreme Court of a state or territory, or the High Court of Australia, as a legal practitioner (however
described); or

(3)a person who is in the

following list: Accountant
Judge
who is:
Justice of the Peace
a) a fellow of the National Tax Accountants’ Association; or
Magistrate
b) a member of any of the following:
Marriage celebrant registered under Subdivision C of Division 1 of
i. Chartered Accountants Australia and New Zealand; Part IV of the Marriage Act 1961
ii. the Association of Taxation and Management Master of a court
Accountants;
Member of the Australian Defence Force who is:
iii. CPA Australia;
a) an officer
iv. the Institute of Public Accountants
b) a non-commissioned officer within the meaning of the
Agent of the Australian Postal Corporation who is in charge of an Defence Force Discipline Act 1982 with 5 or more years
office supplying postal services to the public of continuous service
APS employee engaged on an ongoing basis with 5 or more years c) a warrant officer within the meaning of that
of continuous service who is not specified in another item in this
list Act Member of the Australasian Institute of Mining

Australian Consular Officer or Australian Diplomatic Officer (within and Metallurgy Member of the Governance Institute
the meaning of the Consular Fees Act 1955) of Australia Ltd
Bailiff Member of:
Bank officer with 5 or more continuous years of service a) the Parliament of the Commonwealth
Building society officer with 5 or more years of continuous b) the Parliament of a state
service Chief executive officer of a Commonwealth court c) a territory legislature
Clerk of a court d) a local government authority
Commissioner for Minister of religion registered under Subdivision A of Division 1 of
Affidavits Part IV of the Marriage Act 1961

Commissioner for Declarations Notary public, including a notary public (however described)
exercising functions at a place outside
Credit union officer with 5 or more years of continuous service
a) the Commonwealth
Employee of a Commonwealth authority engaged on a permanent
basis with 5 or more years of continuous service who is not b) the external territories of the Commonwealth
specified in another item in this list Permanent employee of the Australian Postal Corporation with
Employee of the Australian Trade and Investment Commission who 5 or more years of continuous service who is employed in an
is: office providing postal services to the public

(a) in a country or place outside Australia; and Permanent employee of

(b)authorised under paragraph 3 (d) of the Consular Fees Act a) a state or territory or a state or territory authority
1955; and b) a local government authority
(c) exercising the employee’s function at with 5 or more years of continuous service, other than such an
that place Employee of the Commonwealth who employee who is specified in another item of this list

is: Person before whom a statutory declaration may be made under

the law of the State or Territory in which the declaration is made
(a) at a place outside Australia; and
Police officer
(b)authorised under paragraph 3 (c) of the Consular Fees Act
1955; and Registrar, or Deputy Registrar, of a court

(c) exercising the employee’s function at Senior executive employee of a Commonwealth

that place Engineer who is: authority Senior executive employee of a State or

a) a member of Engineers Australia, other than at the Territory

grade of student; or SES employee of the Commonwealth
b) a Registered Professional Engineer of Professionals Sheriff
Australia; or Sheriff’s officer
c) registered as an engineer under a law of the Teacher employed on a permanent full-time or part-time basis at a
Commonwealth, a state or territory; or school or tertiary education institution
d) registered on the National Engineering Register by
Engineers Australia
Finance company officer with 5 or more years of continuous
service Holder of a statutory office not specified in another
item in this list