IN PERMANENT INK

ARKANSAS DEPARTMENT OF HEALTH VITAL RECORDS BRANCH NON-CHEMICAL INDUCED TERMINATION OF PREGNANCY REPORT (REPORT CHEMICAL INDUCED TERMINATION OF PREGNANCY ON VR-29b)

File Date (State Use Only)

1. FACILITY NAME (if not clinic or hospital give address)		2. CITY, TOWN OR LOCATION OF PREGNANCY TERMINATION		3. COUNTY OF PREGNANCY TERMINATION
4. AGE LAST BIRTHDAY		5. MARRIED? ☐ YES ☐ NO		6. DATE OF PREGNANCY TERMINATION (Month, Day, Year)
7a. RESIDENCE - STATE	7b. COUNTY	7c. CITY, TOWN, OR LOCATION		7d. INSIDE CITY LIMITS? ☐ YES ☐ NO	7e. ZIP CODE
8. HISPANIC ORIGIN? (Specify No or Yes - if Yes, specify Cuban Mexican, Puerto Rican, etc.) ☐ NO ☐ YES - Specify:	9. RACE AMERICAN INDIAN ☐ BLACK ☐ WHITE ☐ OTHER - SPECIFY:	10. EDUCATION (Specify only highest grade completed)
			Elementary/Secondary 0-12	College 1-4 or 5+
			11. DATE OF LAST NORMAL MENSES BEGAN (Month, Day, Year)
12. PREVIOUS PREGNANCIES (Complete each section)
LIVE BIRTHS			TERMINATIONS
12a. Now Living Number: ☐ None	12b. Now Dead Number: ☐ None	12c. Spontaneous Number: ☐ None	12b. Induced Number: ☐ None
13. CONSENT (Answer each section)
13a. Was Parental Consent Required? ☐ NO ☐ YES	13b. Was Parental Consent Obtained? ☐ NO ☐ YES	13c. Was Judicial Waiver Obtained? ☐ NO ☐ YES
14. PROBABLE POST-FERTILIZATION AGE (PPF)
14a. PPF Age (Weeks) ☐ Undetermined (Complete 14c)	14b. Method of Determining PPF ☐ Ultrasound ☐ Physical Examination ☐ LMP ☐ Other (Specify):	14c. If PPF Age was undetermined, basis a medical emergency existed:		14d. If PPF Age is 20 weeks or more, basis for immediate abortion of pregnancy:
15. TYPE OF TERMINATION PROCEDURE (Check only one) ☐ (Note: Report chemical induced termination on VR-29b.) Suction Curettage ☐ Dilation and Evacuation (D&E) ☐ Intra-Uterine Instillation (Saline or Prostaglandin) ☐ Sharp Curettage (D&C) ☐ Hysterotomy/Hysterectomy ☐ Other (Specify):	16. WAS THE REASON FOR THE ABORTION DUE RAPE OR INCEST? ☐ NO ☐ YES
			17. WAS THE REASON FOR THE ABORTION TO SAVE THE LIFE OF THE MOTHER? ☐ NO ☐ YES

18. IF PPF AGE IS 20 WEEKS OR MORE, DID METHOD USED PROVIDE THE BEST OPPORTUNITY FOR THE UNBORN CHILD TO SURVIVE?

☐ YES ☐ NO (SPECIFY):

19. DID THE ABORTION RESULT IN A LIVE BIRTH?

☐ NO ☐ YES

20. NAME OF ATTENDING PHYSICIAN (Type or Print):

21. NAME OF STAFF PERSON COMPLETING THE FORM (Type or Print):

INSTRUCTIONS FOR COMPLETING

NON-CHEMICAL INDUCED TERMINATION OF PREGNANCY REPORT: VR-29a

ITEM	INSTRUCTION
1. Facility Name	Enter name of facility or give address if not a clinic or hospital.
2. City, Town, or Location	Enter name of city, town, or location of pregnancy termination.
3. County	Enter name of county where pregnancy termination occurred.
4. Age	Enter age in years of patient at her last birthday.
5. Married	Check 'Yes' if the patient was legally married at any time between conception and termination. Otherwise check 'No.'
6. Date	Enter Month-Day-Year of pregnancy termination (e.g., 10-23-2001).
7. Residence
a. State	Enter name of state in which patient lives.
b. County	Enter name of county in which patient lives.
c. City	Enter name of city in which patient lives.
d. Inside City	Enter Yes or No.
e. ZIP Code	Enter ZIP code of patient's residence.
8. Hispanic Origin	Check No or Yes; If Yes, specify Mexican, Cuban, Puerto Rican, etc.
9. Race	Check White, Black, American Indian, or Other. If Other, specify.
10. Education	Fill in number for highest grade of school completed. If more than 5 years of college, enter 5+.
11. Date of Last Menses	Enter date that last menses began (e.g., 5-14-2001).
12. Previous Pregnancies
a. Now Living	Enter the number of live births that are still living.
b. Now Dead	Enter the number of live births that have died.
c. Spontaneous	Enter the number of spontaneous abortions (miscarriages) that have occurred.
d. Induced	Enter the number of PREVIOUS induced abortions that have occurred.
No. 13 Reference(s): Act 934 of 2015 (§20-16-801)
13. Parental Consent	Check Yes or No on each item
a. Consent Required
b. Consent Obtained
c. Judicial Waiver Obtained
No. 14 Reference(s): Act 171 of 2013 (§20-16-1406)
14. Probable Post-Fertilization (PPF)
a. PPF age	Enter estimate of probable post-fertilization age. Do not use ranges.
b. Method	Check method for determining PPF age
c. PPF Age Undetermined	List the basis of the determination that a medical emergency existed.
d. PPF 20 weeks or more	List the basis of the determination that the pregnant woman had a condition which so complicated her medical condition as to necessitate the immediate abortion of her pregnancy to avert her death or to avert serious risk of substantial and irreversible physical impairment of major bodily function of the pregnant women, not including psychological or emotional condition.
15. Procedure	Check only one type of procedure that terminated this pregnancy.
No. 16 & 17 References(s): Act 787 of 2021 (§20-16-608, §20-16-705(c))
16. Reason Rape or Incest	Check No or Yes.
17. Reason Save Life of Mother	Check No or Yes.
No. 18 Reference(s): Act 171 of 2013 (§20-16-1406)
18. Best Opportunity for Survival	Check Yes or No. If No, specify reason for choice of method.
No. 19 References(s): Act 801 of 2019 (§20-16-604)
19. Did Abortion Result in Live Birth	Check Yes or No
20. Name of Physician	Enter name of attending physician
21. Staff Person Name	Enter name and telephone number of staff person completing this report.

Filing Instructions: The report must be filed monthly. Mail or fax to:

Arkansas Department of Health Health Statistics Branch 4815 West Markham Street, Slot #19 Little Rock, AR 72205 Fax: (501) 661-2544