§ 1-738k. Posting of Individual Abortion Form--Notice--Sample form
Oklahoma Statutes AnnotatedTitle 63. Public Health and Safety
63 Okl.St.Ann. § 1-738k
§ 1-738k. Posting of Individual Abortion Form--Notice--Sample form
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.
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.
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.
Credits
Laws 2010, c. 276, § 3, eff. Nov. 1, 2010; Laws 2013, c. 303, § 1, eff. Nov. 1, 2013.
63 Okl. St. Ann. § 1-738k, OK ST T. 63 § 1-738k
Current with emergency effective legislation through Chapter 182 of the Second Regular Session of the 59th Legislature (2024). Some sections may be more current, see credits for details.
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