Nev. Admin. Code § 50.055
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)
Nev. Admin. Code § 50.055
NRS 50.315