Ill. Admin. Code tit. 77, pt. 505, app B
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?YN (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
Ill. Admin. Code tit. 77, pt. 505, app B