Section 505.APPENDIX B   Induced Termination of Pregnancy Report

 

INDUCED TERMINATION OF PREGNANCY REPORT

 

COMPLETE THIS FORM AND MAIL IT TO:

Illinois Department of Public Health, Division of Vital Records

925 E. Ridgely Ave., Springfield IL 62702-2737

 

(All information submitted shall be confidential pursuant to the Pregnancy Termination Report Code (77 Ill. Adm. Code 505))

 

1.         FACILITY NAME (If not ambulatory surgical treatment centers, hospitals, and other facilities, give address)

 

2.         COUNTY OF PREGNANCY TERMINATION (See County Code table)

 

3.         PATIENT IDENTIFICATION NUMBER

 

4.         REPORTING PHYSICIAN'S IDFPR LICENSE NUMBER

 

5.         PATIENT INFORMATION

 

a.         PATIENT'S RESIDENT STATE (See State Code table)

 

b.         COUNTY (See County Code table)

 

c.         ZIP CODE (Chicago only)

 

6.         RACE/ETHNICITY

 

a.         Race

 

            White

            Black or African American

            American Indian or Alaska Native (Name of the enrolled or principal tribe)

            Asian Indian

            Chinese

            Filipino

            Japanese

            Korean

            Vietnamese

            Other Asian (Specify)

            Native Hawaiian

            Guamanian or Chamorro

            Samoan

            Other Pacific Islander (Specify)

            Other (Specify)

 

b.         Hispanic Origin

 

            No, not Spanish/Hispanic/Latina

            Mexican, Mexican American, Chicana

            Puerto Rican

            Cuban

            Other Spanish/Hispanic/Latina

 

7.         AGE LAST BIRTHDAY

 

8.         MARRIED/CIVIL UNION?

 

9.         DATE OF PREGNANCY TERMINATION (Mo/Day/Year)

 

10.       EDUCATION (Specify only highest grade completed)

 

Elementary/Secondary (0-12)

College (1-4 or 5+)

 

11.       CLINICAL ESTIMATE OF GESTATION (Number of Weeks)

 

12.       PREVIOUS PREGNANCIES (Complete each section)

 

LIVE BIRTHS

 

a.         NOW LIVING (Number)

 

b.         NOW DEAD (Number)

 

OTHER TERMINATIONS

 

a.         SPONTANEOUS (Number)

 

b.         INDUCED (Number) (Do not include this termination)

 

13.       Rh DETERMINATION (Not done/Rh Pos/Rh Neg)

 

14.       IF Rh NEGATIVE, ANTI Rh (Given/Not offered to patient/Refused by patient/Medically not indicated)

 

15.       REASON FOR TERMINATION (Patient's Request/Other)

 

16.       TERMINATION PROCEDURES

 

a.         PROCEDURE THAT TERMINATED PREGNANCY (check only one)

 

            Antiprogestins (such as Mifepristone)

            Suction Curettage

            Sharp Curettage

            Dilation and Evacuation (D & E)

            Intra-Uterine Saline Instillation

            Intra-Prostaglandin Instillation

            Hysterotomy

            Hysterectomy

            Other (Specify)

 

b.         ADDITIONAL PROCEDURES USED FOR THIS TERMINATION, IF ANY

 

17.       COMPLICATIONS OF PREGNANCY TERMINATION?     Y        N   (check all that apply)

 

            Hemorrhage

            Uterine Perforation

            Anesthesia

            Retained Products

            Cervical Laceration

            Infection

            Death

Other (Specify)

 

18.       HOSPITALIZATION REQUIRED AS A RESULT OF COMPLICATION(S)?

   Y        N 

 

19.       This is a corrected version of a previously submitted form.     Y 

 

(Source:  Added at 37 Ill. Reg. 1744, effective January 23, 2013)