Section 505.APPENDIX C   Report of Subsequent Complications after an Induced Termination of Pregnancy

REPORT OF SUBSEQUENT COMPLICATIONS AFTER

AN INDUCED TERMINATION OF PREGNANCY

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 AND ADDRESS WHERE COMPLICATION WAS DIAGNOSED

2.         PATIENT IDENTIFICATION NUMBER

3.         REPORTING PHYSICIAN'S IDFPR LICENSE NUMBER

4.         PATIENT INFORMATION

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

b.         COUNTY (See County Code table)

c.         ZIP CODE (Chicago only)

5.         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

6.         AGE LAST BIRTHDAY

7.         MARRIED/CIVIL UNION?

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

9.         COMPLICATIONS OF PREGNANCY TERMINATION (check all that apply)

            Hemorrhage

            Uterine Perforation

            Anesthesia

            Retained Products

            Cervical Laceration

            Infection

            Death

            Other (Specify)

10.       HOSPITAL ADMISSION REQUIRED ON DATE OF EXAMINATION? 

   Y        N

11.       FACILITY NAME OR LOCATION (IF KNOWN) WHERE THE ABORTION WAS PERFORMED

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