Ill. Admin. Code tit. 77, pt. 505, app C
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?
YN
11. FACILITY NAME OR LOCATION (IF KNOWN) WHERE THE ABORTION WAS PERFORMED
Ill. Admin. Code tit. 77, pt. 505, app C