Thursday, October 8, 2009

Oklahoma Bill H.B. 1595

Here's a link to a .rtf version of the Bill itself.

This is the questionnaire:



Individual Abortion Form
(TO BE COMPLETED FOR EACH ABORTION PERFORMED)
1. Date of abortion _________________
2. County in which abortion performed ________________
3. Age of mother _________________
4. Marital status of mother ________________
(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 ___________
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. Reason for abortion (check all applicable):
Mother cannot afford the child ______
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 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 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. Specialty area of medicine of the physician ___________________
_______________________________________________________________
20. Was ultrasound equipment used before, during, or after the performance of this abortion?
Before? _____ Vaginal, abdominal, or both? _____
During? _____ Vaginal, abdominal, or both? _____
After? _____ Vaginal, abdominal, or both? _____
21. 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 ________
22. 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 _______
23. 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? ______________
24. 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 _____
25. Was the probable gestational age twenty (20) weeks or more? _____
a. If yes, was the mother provided the information described in subsection A of Section 1-738.8 of Title 63 of the Oklahoma Statutes? _____
(1) If yes, was the information provided:
In person ______
By telephone ______
(2) If yes, was the information provided:
By a referring physician _____
An agent of a referring physician _____
The physician performing the abortion _____
An agent of the physician performing the abortion _____
b. Did the mother choose to be given or mailed the materials described in Section 1-738.10 of Title 63 of the Oklahoma Statutes? ___________
c. To the best of the information and belief of the reporting physician, did the mother go on to obtain the abortion? ________
26. 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? ________
27. 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? _________
28. If the answer to question 26 or 27 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
29. Minor’s age ___________
30. 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? ________
31. 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) _________
32. If no notice was provided nor consent obtained, please 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 1-738.1 of Title 63 of the Oklahoma Statutes, existed ___________
Minor received judicial authorization to obtain abortion without parental notice or consent ___________
33. If no notice was provided nor consent obtained because a medical emergency existed, please indicate:
Whether parent was subsequently notified (state period of time elapsed before notice was given) ____________
Whether judicial waiver of notice requirement was obtained ________
34. If the minor received judicial authorization to obtain an abortion without parental notice, please 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 ___________
Filed this ____ day of __________, _____ by:
______________________________
(Name of physician)
_____________________________
(Physician’s license number)

No comments: