Get Induced Abortion Report Form (48 Kb, Pdf) - Dshs Texas

This guide provides clear, step-by-step instructions for filling out the Induced Abortion Report Form as required by the Texas Department of State Health Services. By following these instructions, you can ensure that the form is completed accurately and submitted correctly.

Follow the steps to complete the Induced Abortion Report Form online.

1. Click ‘Get Form’ button to access the Induced Abortion Report Form and open it in your preferred document editor.
2. Begin by entering the report date in the format MM/DD/YYYY. This is the date the report is being filled out.
3. Complete the 'Facility Name' and 'Facility Code' fields to identify the location where the abortion was performed.
4. Fill in the 'Facility City' and 'Facility County' to provide the geographical details of the facility.
5. Under 'TO BE COMPLETED BY PATIENT', enter the patient's date of birth in MM/DD/YYYY format.
6. Indicate the marital status by selecting either 'Married' or 'Single' in the corresponding field.
7. Provide the patient’s county and state of residence. This information is essential for demographic tracking.
8. In the 'Patient's Race/Ethnicity' section, select one option that accurately describes the patient's ethnicity.
9. Move to the 'TO BE COMPLETED BY PHYSICIAN' section and answer whether proof of the patient’s identity and age was obtained.
10. Fill in the 'Abortion Date' and 'Date of Last Menses', also using MM/DD/YYYY format.
11. Estimate the 'Probable Post-Fertilization Age of the Unborn Child' and note the number of previous live births and induced abortions.
12. Indicate if the patient viewed the Woman’s Right to Know Act material and specify the method of pregnancy verification used.
13. Confirm if the patient completed the abortion and sonogram election form.
14. Address whether the patient was under 18 years of age and if consent was obtained in such cases.
15. Select the type of termination procedure according to the options provided.
16. Indicate the type of anesthesia used during the procedure.
17. Detail any complications that arose during the abortion, and describe the method used to dispose of fetal tissue and remains.
18. Confirm if the patient survived the induced abortion, and if applicable, provide the cause of death.
19. If the facility did not perform abortions, check the appropriate box, sign the form, and follow the instructions for returning it via certified mail.
20. Finally, review the completed form for accuracy before saving changes, downloading, or printing the document for submission.

Take the next step by completing and submitting the Induced Abortion Report Form online to ensure compliance with state regulations.