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876878
Unofficial Individual Abortion Form for Training Only
Training form for abortion reporting.
* Indicates Required Field
This form is provided for training purposes only. Do not submit real data using this form. For access to the official form please register using the registration form.
*1. Date of abortion: (Format: mm/dd/yyyy)
*2. County in which abortion was performed:
*3. Age of mother:
*4. Marital status of mother:
*5. Race of mother:
*6. Years of education of mother (specify highest year completed):
*7a. Country of residence of mother:
*7b. State of residence of mother:
*8. Total number of previous pregnancies of the mother:
*>> 8a. Number of previous pregnancies of the mother resulting in live births:
*>> 8b. Number of previous pregnancies of the mother resulting in miscarriages:
*>> 8c. Number of previous pregnancies of the mother resulting in induced abortions:
*9. Approximate gestational age in weeks, as measured from the last menstrual period of the mother, of the unborn child subject to abortion:
*10. Method of abortion used:
>> 10a. Other drug/chemical/medicine method of abortion used, not specified above:
>> 10b. Other method of abortion used, not specified above:
*11. Was there an infant born alive as a result of the abortion? If yes, answer the next two questions.
>> 11a. Were life-sustaining measures undertaken?
>> 11b. How long did the infant survive?
*12. Was anesthesia administered to mother?
>> 12a. If yes to question 12 above, what type?
*13. Was anesthesia administered to the fetus?
>> 13a. If yes to question 13 above, what type?
>> 13b. If yes to question 13 above, how was it administered?
*14. Method of fetal tissue disposal:
*15. Unless a medical emergency, as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes, exists, the abortion provider or agent shall ask the pregnant female to provide, orally or in writing, the reason(s) she is seeking the abortion. If such a medical emergency exists, the abortion provider or agent shall specify on the form the condition which necessitated the immediate abortion:
*>> 15a. REASON GIVEN FOR ABORTION (check all applicable): Having a baby would dramatically change the life of the mother: Having a baby would interfere with the education of the mother: Having a baby would interfere with the job/employment/career of the mother: Mother has other children or dependents: Mother cannot afford the child: Mother is unmarried: Mother is a student or planning to be a student: Mother cannot afford child care: Mother cannot afford the basic needs of life: Mother is unemployed: Mother cannot leave job to care for a baby: Mother would have to find a new place to live: Mother does not have enough support from a husband or partner: Husband or partner is unemployed: Mother is currently or temporarily on welfare or public assistance: Mother does not want to be a single mother: Mother is having relationship problems: Mother is not certain of relationship with the father of the child: Partner and mother are unable to or do not want to get married: Mother is not currently in a relationship: The relationship or marriage of the mother may soon break up: Husband or partner is abusive to the mother or her children: Mother has completed her childbearing: Mother is not ready for a, or another, child: Mother does not want people to know that she had sex or became pregnant: Mother does not feel mature enough to raise a, or another, child: Husband or partner wants mother to have an abortion: There may be possible problem affecting the health of the fetus: Physical health of the mother is at risk: Parents want mother to have an abortion: Emotional health of the mother is at risk: Mother suffered from a medical emergency as defined in Section 1-738.1 of Title 63 of the Oklahoma Statutes: Mother wanted a child of a different sex: Abortion is necessary to avert the death of the mother: Pregnancy was a result of forcible rape: Pregnancy was a result of incest: Other (specify 15b): Patient was asked why she is seeking an abortion, but she declined to give a reason:
>> 15b. Other reason.
*16. Method of payment (check one):
>> 16a. Other method of payment:
17. Type of private medical health insurance coverage, if any (check one):
>> 17a. Other type of private medical health insurance coverage:
*18. Sum of fee(s) collected: (no commas and no $ sign e.g. 2222.00) $
*19. Time of fee collection (check one):
>> 19a. Other Time of Fee Collection
*20. Specialty area of medicine of the physician:
*21a . Was ultrasound equipment used before the performance of this abortion?
*21b. Was ultrasound equipment used during the performance of this abortion?
*21c. Was ultrasound equipment used after the performance of this abortion?
22. If ultrasound equipment was used, was the ultrasound performed by:
>> 22a. Other person performing ultrasound.
*23. Was the information required by paragraph 1 of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to the mother?
>> 23a. If yes, was it provided:
>> 23b. Was it provided by:
*24. Was the information required by paragraph 2 of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes provided to the mother?
>> 24a. If yes, was it provided:
>> 24b. Was it provided by:
*25. Did the mother avail herself of the opportunity to have the printed materials described in Section 1738.3 of Title 63 of the Oklahoma Statutes mailed to her?
*26a. Were the informed consent requirements of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with because of a medical emergency necessitating an immediate abortion to avert death?
*26b. Were the informed consent requirements of subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes dispensed with because of a medical emergency necessitating an immediate abortion to avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy?
*27. Was the probable gestational age of the unborn child twenty (20) weeks or more?
>> 27a. If yes, was the mother provided the information described in subsection A of Section 1-738.8 of Title 63 of the Oklahoma Statutes?
>> >> 27a(1). If yes, was the information provided:
>> >> 27a(2). If yes, was the information provided by:
>> 27b. Did the mother choose to be given or mailed the materials described in Section 1-738.10 of Title 63 of the Oklahoma Statutes?
>> 27c. To the best of the information and belief of the reporting physician, did the mother go on to obtain the abortion?
*28. Was the abortion performed within the scope of employment of an Oklahoma state employee or an employee of an agency or political subdivision of the state?
*29. Was the abortion performed with the use of any public institution, public facility, public equipment, or other physical asset owned, leased, or controlled by this state, its agencies, or political subdivisions?
30. If the answer to question 28 or 29 is yes:
>> 30a. Was the abortion necessary to save the life of the mother?
>> >> 30a(1). If yes, what was the life-endangering condition?
>> 30b. Did the pregnancy result from an act of forcible rape?
>> >> 30b(1). If yes, list the law enforcement authority to which the rape was reported:
>> >> 30b(2). List the date of the report: (Format: mm/dd/yyyy)
>> 30c. Did the pregnancy result from an act of incest committed against a minor?
>> >> 30c(1). If yes, list the law enforcement authority to which the perpetrator was reported:
>> >> 30c(2). List the date of the report: (Format: mm/dd/yyyy)
THIS PORTION TO BE COMPLETED IN CASE OF MINOR
31. Minor’s age at the time the abortion was performed:
>> 31a. City in which the abortion was preformed (added to comply with § 1-740.4a)
32. Was a parent of the minor provided notice prior to the abortion as described in Section 1740.2 of Title 63 of the Oklahoma Statutes?
>> 32a. If yes, how was the notice provided?
>> 32b. If yes, to the best of the reporting physician’s knowledge and belief, did the minor go on to obtain the abortion?
33. Was informed written consent of one parent obtained as described in Section 1-740.2 of Title 63 of the Oklahoma Statutes?
>> 33a. If yes, how was it secured?
>> >> 33a(1). Other(specify):
34. If no notice was provided nor consent obtained, indicate which of the following apply:
35. If no notice was provided nor consent obtained because a medical emergency existed, indicate:
>> 35a. Whether parent was subsequently notified (state period of time elapsed before notice was given):
>> 35b. Whether judicial waiver of notice requirement was obtained:
36. If the minor received judicial authorization to obtain an abortion without parental notice or consent, indicate which of the following applies: Judge ruled that minor was mature enough to give informed consent on her own Judge ruled that abortion was in the best interest of the minor
37. If the female was a minor at the time of conception, indicate the age of the father of the unborn child at the time of conception:
38. If at the time of conception the ages of the mother and father were such that a violation of Section 1111, 1112, 1114 or 1123 of Title 21 or Section 7115 of Title 10 of the Oklahoma Statutes occurred, was the rape or abuse reported to the proper authorities?
*Date Filed: (Format: mm/dd/yyyy)
*Name of physician
*Physician’s license number
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Unofficial Individual Abortion Form for Training Only