§ 63-1-738k. Posting of Individual Abortion Form - Notice - Sample form.  


Latest version.
  • A.  Subsections B and C of this section shall become operative on the later of:

    1.  April 1, 2012; or

    2.  Thirty (30) calendar days following the date on which the State Department of Health posts on its website the Individual Abortion Form and instructions concerning its electronic submission referenced in this section.

    B.  The Department shall post the Individual Abortion Form and instructions concerning its electronic submission on its stable Internet website.  Nothing in the Individual Abortion Form shall contain the name, address, hometown, county of residence, or any other information specifically identifying any patient.  The Department's Individual Abortion Form shall be substantially similar to, but need not be in the specific format, provided in subsection F of this section.

    C.  Any physician performing abortions shall fully complete and submit, electronically, an Individual Abortion Form to the State Department of Health by the last business day of the calendar month following the month in which the physician performs an abortion, for each abortion the physician performs.

    D.  In cases in which a physician or the agent of a physician:

    1.  Mails the printed materials described in Section 1-738.3 of this title to a female specifically to comply with division (1) of subparagraph d of paragraph 2 of subsection B of Section 1-738.2 of this title;

    2.  Gives or mails the printed materials described in Section 1-738.10 of this title to a female specifically to comply with subsection A of Section 1-738.8 of this title; or

    3.  Provides notice to a parent in compliance with Section 1-740.2 of this title,

    but does not subsequently perform an abortion on the female or minor, the physician shall electronically submit a completed Individual Abortion Form to the State Department of Health, and shall mark as "not applicable" those items of information that may accurately be provided only when an abortion is performed.  The physician shall not submit such a form if the physician knows that an abortion was subsequently performed on the female or minor by another physician.  Individual Abortion Forms required by this subsection shall be submitted by the last business day of the second calendar month following the calendar month in which the physician mails the printed materials or provides notice to a parent.

    E.  The Individual Abortion Form shall contain a notice containing an assurance that, in accordance with subsection F of Section 1-738m of this title, public reports based on the form submitted will not contain the name, address, hometown, county of residence, or any other identifying information of any individual female, that the State Department of Health will take care to ensure that none of the information included in its public reports could reasonably lead to the identification of any individual female about whom information is reported in accordance with the Statistical Abortion Reporting Act or of any physician providing information in accordance with the Statistical Abortion Reporting Act, and that such information is not subject to the Oklahoma Open Records Act.

    F.  Individual Abortion Form.  The Department's Individual Abortion Form shall be substantially similar to, but need not be in the specific format of, the following form:

    Individual Abortion Form

    (TO BE COMPLETED FOR EACH ABORTION PERFORMED)

    1.  Date of abortion: _________________

    2.  County in which the abortion was performed: ________________

    3.  Age of mother: _________________

    4.  Marital status of mother: ________________

    (specify married, divorced, separated, widowed, or never married)

    5.  Race of mother: ________________

    6.  Years of education of mother: ________________

    (specify highest year completed)

    7.  State or foreign country of residence of mother:______________

    8.  Total number of previous pregnancies of the mother:___________

    Live Births: _________________

    Miscarriages: _________________

    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:

    Suction Aspiration: ___________

    Dilation and Curettage: ___________

    RU 486: ___________

    Methotrexate: ___________

    Other drug/chemical/medicine (specify): _________________

    Dilation and Evacuation: ___________

    Saline: ___________

    Urea: ___________

    Prostaglandins: ___________

    Partial Birth Abortion: __________

    Hysterotomy: ___________

    Other (specify): ___________

    11.  Was there an infant born alive as a result of the abortion? __________

    If yes:

    Were life-sustaining measures undertaken? ___________

    How long did the infant survive? ___________

    12.  Was anesthesia administered to mother? ____________

    If yes, what type? ____________________________

    13.  Was anesthesia administered to the fetus? ___________

    If yes:

    What type? _______________________

    How was it administered? _______________________

    14.  Method of fetal tissue disposal: _______________________

    15.  Unless a medical emergency, as defined in Section 1-738.1A, or as applicable, Section 1-745.2 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: ___________________

    REASON GIVEN FOR ABORTION (check all applicable):

    Having a baby:

    Would dramatically change the life of the mother: _________

    Would interfere with the education of the mother: _________

    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 1-738.1A of Title 63 of the Oklahoma Statutes: ______

    Mother suffered from a medical emergency as defined in Section 1-745.2 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): ______

    Patient was asked why she is seeking an abortion, but she declined to give a reason: _______

    16.  Method of payment (check one):

    Private insurance: _______

    Public health plan: _______

    Medicaid: _______

    Private pay: _______

    Other (specify): _____________________________

    17.  Type of private medical health insurance coverage, if any (check one):

    Fee-for-service insurance company: ______

    Managed care company: ______

    Other (specify): _____________________________

    18.  Sum of fee(s) collected: ___________

    19.  Time of fee collection (check one):

    Full fee for abortion collected prior to or at the time the patient was provided the information required under subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________

    Partial fee for abortion collected prior to or at the time the patient was provided the information required under subsection B of Section 1-738.2 of Title 63 of the Oklahoma Statutes: _________

    Full fee for abortion collected at time the abortion was performed: ________

    Other (specify): ________

    20.  Specialty area of medicine of the physician: _____________

    At which hospital(s) did the physician have hospital privileges at the time of the abortion?

    ______________________________________________________________

    21.  Was ultrasound equipment used before, during, or after the performance of this abortion?

    Before? _____Vaginal, abdominal, or both? _____

    How long prior to the abortion was the ultrasound performed?

    ______

    Was the mother under the effect of anesthesia at the time of the ultrasound?  ______

    During? _____Vaginal, abdominal, or both? _____

    After? _____Vaginal, abdominal, or both? _____

    If an ultrasound was performed, what was the gestational age of the fetus at the time of the abortion, as determined by the ultrasound?    _____________

    Attach to this form a copy or screenshot of the ultrasound, intact with the date on which the ultrasound was performed, and with the name of the mother redacted; provided, however, such ultrasound shall not be subject to an open records request and shall be subject to HIPAA regulations governing confidentiality and release of private medical records.

    21A.  If an ultrasound was not performed prior to the abortion, was the reason for not performing an ultrasound a medical emergency necessitating an immediate abortion:

    To avert death:  _______

    To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy:  _______

    Other reason:  ____________

    22.  If ultrasound equipment was used, was the ultrasound performed by:

    The physician performing the abortion: _____

    A physician other than the physician performing the abortion: _____

    Other (specify): ___________________________

    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? ___________

    a.If yes, was it provided:

    In person: ___________

    By telephone: ___________

    b.Was it provided by:

    A referring physician: __________

    The physician performing the abortion: _________

    An agent of a referring physician: ___________

    An agent of the physician performing the abortion: ________

    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? _________

    a.If yes, was it provided:

    In person: _______

    By telephone: _______

    b.Was it provided by:

    A referring physician: _______

    An agent of a referring physician: _______

    The physician performing the abortion: ________

    An agent of the physician performing the abortion: _______

    25.  Did the mother avail herself of the opportunity to have the printed materials described in Section 1-738.3 of Title 63 of the Oklahoma Statutes mailed to her? ______________

    26.  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: ______

    To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy: _____

    27.  Was a determination of probable postfertilization age made as required by Section 1-745.5 of Title 63 of the Oklahoma Statutes?     ________

    a.If no, was the determination of probable postfertilization age dispensed with:

    To avert death:   ________

    To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy:  _____

    b.If yes, what was the probable postfertilization age?  ____

    What was the method and basis of the determination?  _____

    What was the basis for the determination to perform the abortion:

    To avert death:  _____

    To avert substantial and irreversible impairment of a major bodily function arising from continued pregnancy:  ____

    Was the method of abortion used one that, in reasonable medical judgment, provided the best opportunity for the unborn child to survive?  _____

    If yes, was there an infant born alive as a result of the abortion?  _____

    If no, what was the basis of the determination?  _____

    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:

    a.Was the abortion necessary to save the life of the mother? _______

    If yes, what was the life-endangering condition? __________

    b.Did the pregnancy result from an act of forcible rape? _______

    If yes, list the law enforcement authority to which the rape was reported: ___________________

    List the date of the report: ___________

    c.Did the pregnancy result from an act of incest committed against a minor? _________

    If yes, list the law enforcement authority to which the perpetrator was reported: ________________

    List the date of the report: ___________

    THIS PORTION TO BE COMPLETED IN CASE OF MINOR

    31.  Minor's age at the time the abortion was performed: ___________

    32.  Was a parent of the minor provided notice prior to the abortion as described in Section 1-740.2 of Title 63 of the Oklahoma Statutes? ________

    a.If yes, how was the notice provided?

    In person: _______

    By mail: _______

    b.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? ______

    If yes, how was it secured?

    In person: ___________

    Other (specify): _________

    34.  If no notice was provided nor consent obtained, indicate which of the following apply:

    Minor was emancipated: ___________

    Abortion was necessary to prevent the death of the minor: _____

    Medical emergency, as defined in Section 1-738.1A of Title 63 of the Oklahoma Statutes, existed: ___________

    Minor received judicial authorization to obtain abortion without parental notice or consent: ___________

    35.  If no notice was provided nor consent obtained because a medical emergency existed, indicate:

    Whether parent was subsequently notified (state period of time elapsed before notice was given): ____________

    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 843.5 of Title 21 of the Oklahoma Statutes occurred, was the rape or abuse reported to the proper authorities? ________

    39.  Were the remains of the fetus after the abortion examined to ensure that all such remains were evacuated from the mother's body? _________

    If the remains of the fetus were examined after the abortion, what was the sex of the child, as determined from such examination? __________

    Was the sex of the child determined prior to the abortion? _________

    If so, by whom? _______

    If so, by what method? _____

    If the sex of the child was determined prior to the abortion, was the mother given information of the child's sex prior to the abortion? ________

    40.  If the abortion was performed without surgery but rather as the result of the administration of chemicals, was the physician present in the same room as the woman to whom the chemicals were administered at the time any such chemicals were first administered? _______

    4l.  Prior to the pregnant woman giving informed consent to having any part of the abortion performed or induced, if the pregnancy was at least eight (8) weeks after fertilization, was the pregnant woman told that it may be possible to make the embryonic or fetal heartbeat of the unborn child audible for the pregnant woman to hear? _______

    Was the pregnant woman asked if she would like to hear the heartbeat? ______

    Was the embryonic or fetal heartbeat of the unborn child made audible for the pregnant woman to hear, using a Doppler fetal heart rate monitor? ______

    If the response to any of the questions in this paragraph was anything other than an unqualified YES, how was the abortion performed in compliance with Sections 1-745.12 through 1-745.19 of Title 63 of the Oklahoma Statutes? ________

    Filed this ____ day of __________, _____, by:

    ______________________________

    (Name of physician)

    _____________________________

    (Physician's license number)

    NOTICE:  In accordance with subsection F of Section 1-738m of Title 63 of the Oklahoma Statutes, public reports based on this form will not contain the name, address, hometown, county of residence, or any other identifying information of any individual female.  The State Department of Health shall take care to ensure that none of the information included in its public reports could reasonably lead to the identification of any individual female about whom information is reported or of any physician providing information in accordance with the Statistical Abortion Reporting Act.  Such information is not subject to the Oklahoma Open Records Act.

    Be advised that any complication(s) shall be detailed in a "Complications of Induced Abortion Report" and submitted to the Department as soon as is practicable after the encounter with the induced-abortion-related illness or injury, but in no case more than sixty (60) days after such an encounter.

Added by Laws 2010, c. 276, § 3, eff. Nov. 1, 2010.  Amended by Laws 2013, c. 303, § 1, eff. Nov. 1, 2013.