20 CAR pt. 1, Appendix C
IN PERMANENT INK
File Date
(State Use Only)
Instructions: Report the total number of chemical abortions performed in each trimester of pregnancy during the quarter. Type or print in ink required information. The report must be filed 15 days after the end of each quarter. Mail to the Arkansas Department of Health, Health Statistics Branch, 4815 West Markham Street, Slot #19, Little Rock, AR 72205 or Fax to (501) 661-2544.
Date Report Completed: ___
Facility Name: _________
Reporting Year: ___
Reporting Quarter (Check one):
☐ First Quarter (1/1 – 3/31)
☐ Second Quarter (4/1 – 6/30)
☐ Third Quarter (7/1 – 9/30)
☐ Fourth Quarter (10/1 - 12/31)
Chemical Abortions Performed During Each Trimester
First Trimester (1-12 weeks): ___
Second Trimester (13-16 weeks): ___
Third Trimester (27 weeks through end of pregnancy): ___
Name Staff Person Completing the Report: _________